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diff --git a/docs_md/articles/cystic-hepatic-mass_85bb9a0b-2d25-457d-a131-20ff07cb552b.md b/docs_md/articles/cystic-hepatic-mass_85bb9a0b-2d25-457d-a131-20ff07cb552b.md
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+++ b/docs_md/articles/cystic-hepatic-mass_85bb9a0b-2d25-457d-a131-20ff07cb552b.md
@@ -0,0 +1,264 @@
+---
+title: "Cystic Hepatic Mass"
+docid: "85bb9a0b-2d25-457d-a131-20ff07cb552b"
+authors:
+ - key: "6c5a9e0e-9dea-461b-9ad4-c00f5c4c2bbf"
+ value: "Atif Zaheer, MD, FSAR"
+ - key: "e987d3d3-1206-48d6-824b-3347c2968855"
+ value: "Michael P. Federle, MD, FACR"
+breadcrumbs:
+ -
+ name: "Gastrointestinal"
+ slug: "gastrointestinal"
+ treeNodeId: "992c2a4d-e0c4-4b82-be00-a05f5f19e3be"
+ -
+ name: "Differential Diagnosis"
+ slug: "differential-diagnosis"
+ treeNodeId: "b2773887-e8a2-40b6-86b5-3bd2e3ba7c30"
+ -
+ name: "Liver"
+ slug: "liver"
+ treeNodeId: "c1682329-7d88-44f2-bd0f-bccf589e5631"
+ -
+ name: "Generic Imaging Patterns"
+ slug: "generic-imaging-patterns"
+ treeNodeId: "4f8b9a53-d6d2-4981-ab07-978042118376"
+ -
+ name: "Cystic Hepatic Mass"
+ slug: "cystic-hepatic-mass"
+ treeNodeId: null
+category: "Gastrointestinal"
+documentVersionId: "4bcc64c4-b69d-476f-af6c-eee81bea6bd5"
+imageCount: 22
+lastUpdated: "07/29/22"
+pageDescription: "Cystic Hepatic Mass"
+pageKeywords: "Gastrointestinal, Differential Diagnosis, Liver, Generic Imaging Patterns, Cystic Hepatic Mass"
+pageTitle: "Cystic Hepatic Mass | STATdx"
+enhancedTitle: "Cystic Hepatic Mass"
+type: "DDX"
+breadcrumbs:
+ - "Gastrointestinal"
+ - "Differential Diagnosis"
+ - "Liver"
+ - "Generic Imaging Patterns"
+ - "Cystic Hepatic Mass"
+---
+## ESSENTIAL INFORMATION
+
+- ### Key Differential Diagnosis Issues
+
+
+ - Any mural nodularity or debris level within cyst should raise concern for tumor, abscess, or hematoma
+ - Essential to compare current study with prior studies to observe for interval change
+ - Simple cysts change size only slowly
+ - Abscesses change quickly
+ - Treated tumors may simulate cysts [especially gastrointestinal stromal tumor (GIST)]
+ - View images in multiple planes
+ - Coronal and sagittal imaging often help to show true morphology, number, and etiology of cystic mass
+- ### Helpful Clues for Common Diagnoses
+
+
+ - **Hepatic Cyst**
+ - Water attenuation, no visible wall
+ - No enhancement of cyst contents
+ - MR: Very bright on T2, dark on T1 imaging; no enhancement or mural nodularity
+ - US: Sonolucent with acoustic enhancement; no visible wall or nodularity
+ - Hemorrhage within simple cyst can be difficult to distinguish from cystic neoplasm
+ - 1 or 2 thin septa may be seen
+ - Often multiple, of varying sizes
+ - **Autosomal Dominant Polycystic Disease, Liver**
+ - Many cysts of varying sizes
+ - Intracyst bleeding results in high-attenuation fluid and calcified cyst walls
+ - 2 forms of polycystic liver disease (PLD): Isolated PLD and PLD in association with polycystic kidney disease (PKD)
+ - Often results in massive hepatomegaly, but rarely impairs liver function
+ - May be associated with cysts in other organs
+ - Usually have history of other family members with polycystic disease
+ - Cannot diagnose autosomal dominant polycystic liver disease just by presence of numerous hepatic cysts
+ - Requires cysts in other organs, family history, or genetic testing
+ - **Hepatic Pyogenic Abscess**
+ - Multiloculated, multiseptate cluster of complex cysts
+ - Wall and septa may show contrast enhancement
+ - Associated atelectasis and pleural effusion when abscess occurs in peripheral liver adjacent to diaphragm
+ - Etiology
+ - Prior surgery or trauma
+ - Cholecystitis or cholangitis
+ - Hematogenous spread from colon
+ - Double target sign: Pus surrounded by pyogenic membrane surrounded by edema
+ - **Biliary Hamartomas**
+ - Mimic cysts on CT and MR
+ - Multiple small (1-1.5 cm), low-attenuation lesions ± echogenic nodules in walls
+ - Lack of larger cystic lesions and cysts in other organs distinguishes this from autosomal dominant polycystic disease
+ - Should be considered as likely diagnosis in setting of innumerable small, slightly complex "cysts" in healthy patient
+ - **Metastases, Hepatic**
+ - Most common etiologies
+ - From primary cystic tumor (e.g., ovarian)
+ - Ovarian primary, sarcomas, GIST, etc. after treatment
+ - GIST metastasis treated with Gleevec may mimic simple cyst (check history and prior studies)
+ - Squamous cell metastases and mucinous adenocarcinoma mets may appear cystic
+ - Most have mural nodularity on CT, US, and MR
+ - **Hepatic Amebic Abscess**
+ - Solitary, peripheral, round or ovoid mass
+ - Endemic in certain populations
+ - Imaging appearance, clinical presentation, and serology are diagnostic
+ - **Biloma/Seroma**
+ - Following trauma, partial liver resection, radiofrequency ablation
+ - Uninfected biloma or seroma does not require drainage
+ - Often takes weeks to months for large lesions to resolve
+ - In setting of liver transplantation, may result from hepatic artery thrombosis with biliary necrosis
+ - Biloma in hepatic allograft is ominous finding
+ - **Steatosis (Fatty Liver) (Mimic)**
+ - Focal deposits may be near-water density on NECT (but echogenic, not cystic, on US)
+ - MR also definitive, showing selective signal dropout from focal steatotic areas on opposed-phase GRE imaging
+- ### Helpful Clues for Less Common Diagnoses
+
+
+ - **Hepatic Candidiasis**
+ - Innumerable microabscesses (< 1 cm) with target or wheel appearance
+ - Occur in immune-compromised patients
+ - Fungal and mycobacterial opportunistic organisms may cause similar appearance
+ - **Hepatic Hydatid Cyst**
+ - Solitary or multiple
+ - Discrete peripheral wall ± calcification
+ - Mother cyst contains hydatid matrix/sand, daughter cysts
+ - Daughter cysts may be smaller spheres within larger cyst or appear as thick septations
+ - **Biliary Cystadenoma/Carcinoma**
+ - Asymptomatic until large
+ - Solitary, multiseptate mass with discrete enhancing wall and septa
+ - Rarely have no visible septa
+ - Complete resection of all parts of tumor essential to prevent recurrence
+ - Typically in middle-aged women
+ - **Biliary Intraductal Papillary Mucinous Neoplasm**
+ - Intraductal papillary mucinous neoplasm
+ - Analogous to pancreatic intraductal papillary mucinous neoplasm
+ - Tumor within bile duct may rarely produce mucin that distends ducts and may simulate cystic mass
+ - May see nodular, enhancing component (worrisome for cholangiocarcinoma)
+ - **Hepatocellular Carcinoma**
+ - Spontaneous necrosis (or following treatment) may simulate cystic mass
+ - Usually have solid component with arterial hyperenhancement and delayed washout
+ - **Caroli Disease**
+ - Cystic dilation of intrahepatic bile ducts
+ - Communication with bile ducts is key feature, distinguishing it from other cystic masses
+ - Recommend MRCP or ERCP
+ - Central dot sign: Dilated ducts surrounding portal vein radicle
+ - **Undifferentiated Hepatic Sarcoma**
+ - Undifferentiated sarcoma, primary to liver
+ - Rare tumor with very aggressive clinical course
+ - Typical appearance is large (usually > 10 cm), solitary, encapsulated mass
+ - Peripheral hypervascular solid component
+ - Often has large complex, cystic spaces with focal hemorrhage
+ - Paradoxical appearance: Predominantly solid appearance on US and cystic-like appearance on CT/MR due to high water content of prominent myxoid stroma
+ - **Intrahepatic Pseudocyst**
+ - May dissect into liver along portal triads
+ - Intrahepatic pseudocyst usually has adjacent cyst in pancreatic head
+ - Check for imaging and clinical evidence of pancreatitis
+ - **Hepatic Inflammatory Pseudotumor**
+ - a.k.a. inflammatory myofibroblastic tumor
+ - Relatively rare with variable appearance
+ - Usually resemble cholangiocarcinoma with delayed, persistent enhancement
+ - Rarely has multiseptate, cystic appearance
+ - **Ciliated Hepatic Foregut Cyst**
+ - Rare congenital anomaly
+ - Typically small (< 3 cm), cystic mass in segment IV of liver
+ - May appear complex or solid on US
+
+
+## Images
+
+
+### Selected Images
+
+
with water density, homogeneous contents. No internal debris or wall irregularities are present.](images/app.statdx.com_image_thumbnail_dd33f12a-c92e-44ca-9a42-e3ed0b27eb91_annotated_true_size_900_quality_90_86fade005a0afd96e642545eb947db1844dcb402.jpg)
+**Hepatic Cyst**
+*Axial CECT in a 79-year-old woman shows a spherical liver mass with water density, homogeneous contents. No internal debris or wall irregularities are present.*
+
+
+**Hepatic Cyst**
+*Axial CECT in a 79-year-old woman shows a spherical liver mass with water density, homogeneous contents. No internal debris or wall irregularities are present.*
+
+
+**Autosomal Dominant Polycystic Disease, Liver**
+*Axial CECT shows innumerable hepatic cysts of water attenuation and varying size, causing hepatomegaly. Only a few small renal cysts are present, and renal function is normal.*
+
+
+**Hepatic Pyogenic Abscess**
+*Axial CECT shows a liver mass with innumerable septa and slightly higher than water density contents . Needle aspiration yielded a small quantity of pus, and a catheter was inserted for drainage. The etiology was subacute diverticulitis.*
+
+
+**Biliary Hamartomas**
+*Axial CECT in a 53-year-old man shows innumerable small, cystic lesions throughout the liver, ranging in size from 2-15 mm. The lesions are often not perfectly spherical, and many have visible nodular enhancement within their walls.*
+
+
to background liver. All are typical features of biliary hamartomas.](images/app.statdx.com_image_thumbnail_4c827181-4c48-439c-a5cd-a7e79d02ce5b_annotated_true_size_900_quality_90_607d7ca685079ba9b060ea55ad7c0776b60ae85c.jpg)
+**Biliary Hamartomas**
+*US shows only the lesions > 10 mm as cystic structures , while the smaller lesions are hyperechoic to background liver. All are typical features of biliary hamartomas.*
+
+
+**Biliary Hamartomas**
+*Coronal MRCP shows innumerable small, T2-hyperintense lesions that do not communicate with the biliary tree.*
+
+
. The subtle mural nodule 
is the clue that this is a neoplasm (metastatic thyroid cancer).](images/app.statdx.com_image_thumbnail_d0679796-e152-437e-92ad-489baa2acd92_annotated_true_size_900_quality_90_1daba69179ee9c5998db371ddb41dbb62693c37a.jpg)
+**Metastases, Hepatic**
+*Axial CECT shows several hypodense hepatic masses, including 1 cystic lesion . The subtle mural nodule is the clue that this is a neoplasm (metastatic thyroid cancer).*
+
+
+**Hepatic Amebic Abscess**
+*Axial CECT shows a shaggy, encapsulated, solitary cystic mass with nonenhancing contents, representing a typical amebic abscess. The imaging appearance, clinical presentation, and serology usually suffice for diagnosis.*
+
+
+**Biloma/Seroma**
+*Axial CECT 3 weeks after a blunt traumatic liver laceration shows a lobulated, cystic lesion that represents a combination of walled-off bile and blood, also known, respectively, as biloma and seroma. Clinical history and comparison with prior CT scans provide confident diagnosis.*
+
+
+**Hepatic Candidiasis**
+*Axial CECT in a febrile, immune-suppressed patient shows innumerable small, hypodense lesions in the liver with irregular walls. Other opportunistic hepatic infections may have a similar appearance.*
+
+
+**Hepatic Hydatid Cyst**
+*Coronal CECT in immigrant from Middle East shows 2 large, multiseptate, cystic masses . Within outer pericyst are multiple daughter cysts or scolices. Imaging appearance, coupled with serology, is usually sufficient for diagnosis.*
+
+
+**Biliary Cystadenoma/Carcinoma**
+*Coronal CECT in a middle-aged woman shows complex, cystic mass, lobulated margins, enhancing wall and septa . These findings with no other known tumor could be considered sufficiently diagnostic of biliary cystadenoma to warrant resection without further evaluation.*
+
+
+**Biliary Intraductal Papillary Mucinous Neoplasm**
+*Axial CECT of biliary IPMN with cholangiocarcinoma shows dilated intrahepatic bile ducts and a cystic mass . ERCP showed opacification of the cyst with contrast and the presence of surface nodularity within the bile ducts.*
+
+
, and multiple hepatic cysts. These represent dilated intrahepatic bile ducts, draped around the central dot of accompanying portal veins 
.](images/app.statdx.com_image_thumbnail_3ecd123c-87be-4556-94e3-50a90ab28330_annotated_true_size_900_quality_90_fa5aad2dfb99e7efac6acef45b59ee86303ff0dd.jpg)
+**Caroli Disease**
+*Axial CECT in a woman with portal hypertension due to congenital hepatic fibrosis and Caroli disease shows splenomegaly, varices , and multiple hepatic cysts. These represent dilated intrahepatic bile ducts, draped around the central dot of accompanying portal veins .*
+
+
+**Undifferentiated Hepatic Sarcoma**
+*Coronal CECT in a man with RUQ pain shows a huge, multiseptate, cystic mass with enhancing peripheral components. Intraperitoneal blood was due to capsular rupture of this undifferentiated primary hepatic sarcoma.*
+
+
+**Ciliated Hepatic Foregut Cyst**
+*Axial T2 MR in a 29-year-old woman with a solid-appearing mass on US shows a complex, cystic-appearing mass in segment 4 that had no enhancement on other sequences. Resection proved ciliated hepatic foregut cyst.*
+
+
+### Additional Images
+
+
+**Hepatic Cyst**
+*Axial CECT shows an unusually large, simple hepatic cyst that caused compression and obstruction of the intrahepatic bile ducts .*
+
+
+**Hepatic Cyst**
+*Axial T2 FS MR shows several large, contiguous hepatic cysts. Hemorrhage within the cysts accounts for decreased signal intensity within portions of the cysts .*
+
+
+**Biloma/Seroma**
+*Axial CECT shows an irregular cystic lesion within a transplanted liver. This is a biloma with biliary necrosis as a result of hepatic artery thrombosis.*
+
+
+**Biloma/Seroma**
+*Axial CECT shows dilated bile ducts, peribiliary hepatic fluid, and a cystic biloma in a liver allograft, as a result of hepatic artery thrombosis.*
+
+
+**Metastases, Hepatic**
+*Axial CECT shows a heterogeneous, solid mass in the left lobe (that subsequently underwent cystic necrosis with treatment). This was found to be metastatic gastric GIST.*
+
+
+**Metastases, Hepatic**
+*Axial CECT shows a cystic lesion in the left lobe. This is a metastatic gastric GIST that responded to Gleevec therapy with complete necrosis.*
+
diff --git a/docs_md/articles/focal-liver-lesion-with-hemorrhage_5e6be44f-07d3-4569-abe3-798d7513fe41.md b/docs_md/articles/focal-liver-lesion-with-hemorrhage_5e6be44f-07d3-4569-abe3-798d7513fe41.md
new file mode 100644
index 0000000..e19bfd1
--- /dev/null
+++ b/docs_md/articles/focal-liver-lesion-with-hemorrhage_5e6be44f-07d3-4569-abe3-798d7513fe41.md
@@ -0,0 +1,205 @@
+---
+title: "Focal Liver Lesion With Hemorrhage"
+docid: "5e6be44f-07d3-4569-abe3-798d7513fe41"
+authors:
+ - key: "6c5a9e0e-9dea-461b-9ad4-c00f5c4c2bbf"
+ value: "Atif Zaheer, MD, FSAR"
+ - key: "e987d3d3-1206-48d6-824b-3347c2968855"
+ value: "Michael P. Federle, MD, FACR"
+breadcrumbs:
+ -
+ name: "Gastrointestinal"
+ slug: "gastrointestinal"
+ treeNodeId: "992c2a4d-e0c4-4b82-be00-a05f5f19e3be"
+ -
+ name: "Differential Diagnosis"
+ slug: "differential-diagnosis"
+ treeNodeId: "b2773887-e8a2-40b6-86b5-3bd2e3ba7c30"
+ -
+ name: "Liver"
+ slug: "liver"
+ treeNodeId: "c1682329-7d88-44f2-bd0f-bccf589e5631"
+ -
+ name: "Generic Imaging Patterns"
+ slug: "generic-imaging-patterns"
+ treeNodeId: "4f8b9a53-d6d2-4981-ab07-978042118376"
+ -
+ name: "Focal Liver Lesion With Hemorrhage"
+ slug: "focal-liver-lesion-with-hemorrhage"
+ treeNodeId: null
+category: "Gastrointestinal"
+documentVersionId: "064d4855-c1ec-4e1b-be48-f200fa59ea40"
+imageCount: 23
+lastUpdated: "09/15/22"
+pageDescription: "Focal Liver Lesion With Hemorrhage"
+pageKeywords: "Gastrointestinal, Differential Diagnosis, Liver, Generic Imaging Patterns, Focal Liver Lesion With Hemorrhage"
+pageTitle: "Focal Liver Lesion With Hemorrhage | STATdx"
+enhancedTitle: "Focal Liver Lesion With Hemorrhage"
+type: "DDX"
+breadcrumbs:
+ - "Gastrointestinal"
+ - "Differential Diagnosis"
+ - "Liver"
+ - "Generic Imaging Patterns"
+ - "Focal Liver Lesion With Hemorrhage"
+---
+## ESSENTIAL INFORMATION
+
+- ### Key Differential Diagnosis Issues
+
+
+ - Hemorrhage may be detected as heterogeneous high attenuation (> 60 HU on NECT), or high-intensity foci on T1WI and T2WI
+ - Bleeding may include subcapsular and intraperitoneal extension
+- ### Helpful Clues for Common Diagnoses
+
+
+ - **Hepatic Trauma**
+ - Blunt or penetrating (including biopsies, TIPS, etc.)
+ - Hepatic lacerations usually have linear or stellate configuration
+ - Location: Right lobe (75%), left lobe (25%)
+ - Best imaging tool: Dual-phase CT in hemodynamically stable patients
+ - **Hepatic Adenoma**
+ - Foci of hemorrhage within tumor is common feature on MR, less common on CT
+ - Spontaneous bleeding within or around hepatic mass in young female without cirrhosis is almost diagnostic of adenoma
+ - Other signs of adenoma
+ - Lipid or fat content
+ - Multiplicity
+ - Encapsulation
+ - **Hepatocellular Carcinoma**
+ - Spontaneous hemorrhage within tumor is uncommon
+ - Spontaneous rupture through capsule is relatively common for large hepatocellular carcinoma (HCC)
+ - Other signs of HCC
+ - Occurrence within cirrhotic liver
+ - Hypervascularity with washout
+ - Encapsulation
+ - **Hepatic Cyst**
+ - Isolated or part of autosomal dominant polycystic disease
+ - Clotted blood in cyst may be mistaken for tumor but will not show enhancement
+- ### Helpful Clues for Less Common Diagnoses
+
+
+ - **Coagulopathic Hemorrhage, Liver**
+ - Spontaneous intrahepatic or perihepatic hemorrhage is rare manifestation of coagulopathy or anticoagulant therapy
+ - Spherical hematoma within liver may simulate tumor
+ - Others signs of coagulopathic hemorrhage
+ - Hematocrit sign (fluid level) within hematoma
+ - Multiple sites of bleeding
+ - Favored sites: Iliopsoas and rectus muscles
+ - **Hepatic Metastases**
+ - Hemorrhage is uncommon, usually associated with hypervascular metastases
+ - May occur following chemotherapy or transhepatic ablation of metastatic lesions
+ - Most commonly: Lung cancer, renal cell carcinoma, pancreatic neuroendocrine tumor, and melanoma
+ - **HELLP Syndrome**
+ - Hemolysis, elevated liver enzymes, low platelets
+ - Severe variation of toxemia of pregnancy
+ - Intrahepatic or subcapsular fluid collection (hematoma)
+ - Occasionally active extravasation
+ - Wedge-shaped areas of infarction
+ - **Amyloidosis**
+ - Hepatocellular rupture extremely rare
+
+
+## Images
+
+
+### Selected Images
+
+
+**Hepatic Trauma**
+*Axial CECT in a trauma victim shows a broad hepatic laceration with foci of active bleeding and hemoperitoneum . Note adjacent rib fractures .*
+
+
+**Hepatic Trauma**
+*Axial CECT in a trauma victim shows a broad hepatic laceration with foci of active bleeding and hemoperitoneum . Note adjacent rib fractures .*
+
+
+**Hepatic Trauma**
+*Axial NECT in a patient with a falling hematocrit following liver biopsy shows high-density blood in a linear tract deep within the liver , representing the biopsy site and depth. Also note the extension as a subcapsular hematoma, the lentiform collection lateral to the liver .*
+
+
+**Hepatic Adenoma**
+*Axial CECT in a young woman shows a hypervascular mass in the right lobe with a large, spontaneous subcapsular hematoma .*
+
+
+**Hepatic Adenoma**
+*Axial NECT in a young woman with acute pain shows a mass in the lateral segment with high-attenuation material centrally due to an acute hematoma.*
+
+
+**Hepatic Adenoma**
+*Axial T1 MR in a young woman shows a hepatic mass containing several hyperintense foci that represent hemorrhage. The foci were hyperintense on T2 as well, distinguishing hemorrhage from fat as the etiology.*
+
+
+**Hepatocellular Carcinoma**
+*Arterial-phase CECT in a man with cirrhosis and sudden right upper quadrant (RUQ) pain shows tumor vessels within a poorly defined, hypervascular mass . Ascites and a sentinel clot overlying the hepatic mass are seen. Spontaneous rupture of hepatocellular carcinoma was the etiology.*
+
+
+**Hepatocellular Carcinoma**
+*Arterial-phase CECT in the same patient shows part of the hypervascular mass , as well as the ascites and sentinel clot overlying the site of the capsular rupture. A catheter angiogram confirmed bleeding hepatocellular carcinoma. It was treated with coil embolization.*
+
+
+**Hepatocellular Carcinoma**
+*Axial NECT in a 60-year-old man with alcoholic liver disease and sudden RUQ pain shows a hyperdense sentinel clot within and around the liver as well as a spherical hepatic mass .*
+
+
+**Hepatocellular Carcinoma**
+*Coronal CECT in a woman with cirrhosis and sudden RUQ pain shows a heterogeneous, encapsulated mass that was hyperdense on arterial phase. There is generalized ascites but also a sentinel clot over the mass, indicating the source of bleeding.*
+
+
+**Hepatic Cyst**
+*Axial CECT shows a large mass with a thin wall, characteristic of a simple cyst. Within the cyst is a heterogeneous focus of higher attenuation , suggestive of acute hemorrhage. Other sections showed hemorrhagic ascites.*
+
+
+**Hepatic Cyst**
+*Grayscale ultrasound shows a hepatic cyst containing a heterogeneous organizing hematoma with fibrin strands .*
+
+
+**Hepatic Cyst**
+*Axial FS T2 MR shows a large, complex cystic mass with dependent settling of material that is hypointense on T2, indicating subacute hemorrhage.*
+
+
+**Autosomal Dominant Polycystic Disease, Liver**
+*Axial T1 GRE opposed-phase MR shows many cysts within an enlarged liver. Many of the cysts are of water intensity (dark on this T1), while others are bright, due to hemorrhage.*
+
+
, active bleeding 
, and multiple sites of bleeding, including hepatic and renal .](images/app.statdx.com_image_thumbnail_8ee4c117-7d86-4689-914e-061501207fb9_annotated_true_size_900_quality_90_078a6c0a25b221613c305340a16b362041b37303.jpg)
+**Coagulopathic Hemorrhage, Liver**
+*Axial CECT shows signs of coagulopathic hemorrhage, including the hematocrit sign , active bleeding , and multiple sites of bleeding, including hepatic and renal .*
+
+
+**Coagulopathic Hemorrhage, Liver**
+*Axial CECT in a patient who was taking anticoagulant medication shows hepatic defects that resemble fracture planes , but there was no history of trauma. A subcapsular hematoma and hemoperitoneum are also shown. All findings resolved with withdrawal of the medication. No underlying hepatic mass or other pathology was found.*
+
+
+**Hepatic Metastases**
+*Axial CECT shows a large metastatic lesion in the liver from a pancreatic neuroendocrine tumor with a subcapsular hematoma from spontaneous bleeding.*
+
+
+**Hepatic Metastases**
+*Axial CECT in a 55-year-old man with melanoma shows metastasis to the liver that is peculiarly heterogeneous and high density, perhaps indicating bleeding within the metastasis.*
+
+
+**Hepatic Metastases**
+*Axial CECT in a patient with metastatic melanoma and acute RUQ pain shows a hepatic mass . Immediately adjacent to this metastasis is a heterogeneous sentinel clot , strongly suggesting bleeding from the metastases. Also noted is an extensive hemoperitoneum with an attenuation of 35 HU.*
+
+
+**HELLP Syndrome**
+*Axial CECT in a young woman with toxemia and sudden RUQ pain shows a massive subcapsular and perihepatic hematoma , along with active bleeding and heterogeneous enhancement of the hepatic parenchyma .*
+
+
+**HELLP Syndrome**
+*Axial CECT in a postpartum woman with RUQ pain shows a large, subcapsular hematoma and hepatic infarcts .*
+
+
+### Additional Images
+
+
+**Hepatic Trauma**
+*Axial NECT shows a deep linear focus of hyperdensity and a subcapsular collection of similar appearance. The hematoma was due to a percutaneous liver biopsy.*
+
+
+**Hepatic Adenoma**
+*Axial T1 FS MR shows peripheral foci of hyperintensity on T1 that remained hyperintense on T2, indicating hemorrhage. This was hepatic adenoma.*
+
+
+**HELLP Syndrome**
+*In this woman with HELLP syndrome and spontaneous bleeding, a selective hepatic arteriogram indirectly shows the subcapsular hematoma as the liver is displaced medially. It also shows multiple foci of active hemorrhage , which were treated with coil embolization.*
+
diff --git a/docs_md/articles/hepatic-cyst_e525e5da-75e8-432c-b398-cb3d18e97771.md b/docs_md/articles/hepatic-cyst_e525e5da-75e8-432c-b398-cb3d18e97771.md
new file mode 100644
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--- /dev/null
+++ b/docs_md/articles/hepatic-cyst_e525e5da-75e8-432c-b398-cb3d18e97771.md
@@ -0,0 +1,548 @@
+---
+title: "Hepatic Cyst"
+docid: "e525e5da-75e8-432c-b398-cb3d18e97771"
+authors:
+ - key: "6c5a9e0e-9dea-461b-9ad4-c00f5c4c2bbf"
+ value: "Atif Zaheer, MD, FSAR"
+ - key: "e987d3d3-1206-48d6-824b-3347c2968855"
+ value: "Michael P. Federle, MD, FACR"
+breadcrumbs:
+ -
+ name: "Gastrointestinal"
+ slug: "gastrointestinal"
+ treeNodeId: "992c2a4d-e0c4-4b82-be00-a05f5f19e3be"
+ -
+ name: "Diagnosis"
+ slug: "diagnosis"
+ treeNodeId: "65118aca-7db6-4b7c-becd-30be67d24e37"
+ -
+ name: "Liver"
+ slug: "liver"
+ treeNodeId: "3a84cf33-306e-40bb-9947-975013d43188"
+ -
+ name: "Benign Neoplasms and Tumor-Like Conditions"
+ slug: "benign-neoplasms-and-tumor-like-co-"
+ treeNodeId: "1e980f1f-b0c1-4d58-9db2-e38b65e47d29"
+ -
+ name: "Hepatic Cyst"
+ slug: "hepatic-cyst"
+ treeNodeId: null
+category: "Gastrointestinal"
+documentVersionId: "afd0a54d-752e-4b6d-9140-2e67130414a8"
+imageCount: 43
+lastUpdated: "04/23/25"
+pageDescription: "Hepatic Cyst"
+pageKeywords: "Gastrointestinal, Diagnosis, Liver, Benign Neoplasms and Tumor-Like Conditions, Hepatic Cyst"
+pageTitle: "Hepatic Cyst | STATdx"
+enhancedTitle: "Hepatic Cyst"
+type: "DX"
+references: true
+ddx: true
+cases: 2
+breadcrumbs:
+ - "Gastrointestinal"
+ - "Diagnosis"
+ - "Liver"
+ - "Benign Neoplasms and Tumor-Like Conditions"
+ - "Hepatic Cyst"
+---
+## KEY FACTS
+
+- ### Terminology
+
+
+ - Simple hepatic cyst is benign, congenital, developmental lesion derived from biliary endothelium
+- ### Imaging
+
+
+ - Congenital or developmental
+ - Simple hepatic or bile duct cyst
+ - Often multiple: Usually < 10
+ - When > 10, consider autosomal dominant polycystic liver disease (ADPLD) or biliary hamartomas
+ - Sharply defined margins, thin walls
+ - Water density (-10 to +10 HU)
+ - Usually no or few thin septations
+ - No mural nodularity or wall calcification
+ - Hemorrhage into cyst may simulate tumor
+ - No enhancement of "solid" material
+ - Varied MR signal intensity (due to mixed blood products)
+ - US: Anechoic mass, accentuated through transmission
+ - Smooth borders; thin or invisible wall
+ - Size varies from few mm to > 20 cm
+ - Cysts are rarely of similar size
+ - Helps to differentiate from biliary hamartomas, which are all usually < 15 mm
+- ### Top Differential Diagnoses
+
+
+ - Autosomal dominant polycystic disease, liver
+ - Cystic or necrotic metastases
+ - Mucinous cystic neoplasm of liver
+ - Biliary hamartomas
+ - Ciliated hepatic foregut cyst
+ - Hepatic cavernous hemangioma
+ - Biloma
+ - Hepatic pyogenic abscess
+ - Hydatid (echinococcal) disease
+- ### Diagnostic Checklist
+
+
+ - Sonography shows cyst morphology better than CT
+
+## TERMINOLOGY
+
+- ### Synonyms
+
+
+ - Simple hepatic or bile duct cyst
+- ### Definitions
+
+
+ - Benign, congenital, developmental lesion derived from biliary endothelium
+
+## IMAGING
+
+- ### General Features
+
+
+ - #### Best diagnostic clue
+
+
+ - Anechoic lesion with increased through transmission and no mural nodularity on US
+ - #### Location
+
+
+ - Any location within liver
+ - #### Size
+
+
+ - Varies from few mm to > 20 cm
+ - Cysts are rarely of similar size
+ - Helps to differentiate from biliary hamartomas, which are all usually < 15 mm
+ - #### Morphology
+
+
+ - Spherical or oval, well marginated
+ - Key concepts
+ - Classified based on etiology and pathogenesis
+ - Congenital or developmental: Simple hepatic or bile duct cyst
+ - Often multiple: Usually < 10
+ - No communication with bile ducts
+ - When > 10 in number, fibropolycystic disease must be considered
+ - i.e., autosomal dominant polycystic liver disease (ADPLD) or biliary hamartomas
+- ### CT Findings
+
+
+ - #### NECT
+
+
+ - Simple liver or bile duct cyst
+ - Sharply defined margins; thin walls
+ - Water density (-10 to +10 HU)
+ - Usually no septations (uncommonly ≥ 1 thin septa)
+ - No fluid-debris levels
+ - No mural nodularity or wall calcification
+ - Hemorrhage into cyst may be indistinguishable from tumor
+ - Mural nodularity, fluid-debris level
+ - No enhancement of "solid" material
+ - #### CECT
+
+
+ - Simple cyst
+ - Uncomplicated or complex
+ - No enhancement of cyst contents
+- ### MR Findings
+
+
+ - Simple hepatic cyst
+ - T1WI: Hypointense
+ - Heavily T2WI
+ - Markedly increased signal intensity due to pure fluid content
+ - Sometimes indistinguishable from hemangioma
+ - Complicated (hemorrhagic) cyst
+ - T1WI
+ - Higher signal intensity (due to mixed blood products)
+ - May or may not show fluid level
+ - T2WI
+ - Low signal due to hemorrhagic products
+ - May have mural nodularity due to presence of clot
+ - Neovascularization within organized hematoma may occur
+ - Progressive centrifugal enhancement pattern on dynamic contrast-enhanced CT or MR
+ - Hypointense rim with central hyperintensity on T2WI
+ - Cyst wall calcification
+ - T1WI C+
+ - Uncomplicated or complicated cyst
+ - No enhancement of contents
+ - Subtraction imaging may help
+ - MRCP
+ - Shows no communication with bile ducts
+- ### Ultrasonographic Findings
+
+
+ - #### Grayscale ultrasound
+
+
+ - Uncomplicated simple cyst
+ - Anechoic mass; accentuated through transmission
+ - Smooth borders; thin or invisible wall
+ - No or few septations
+ - No mural nodules or wall calcification
+ - Hemorrhagic or infected hepatic cyst
+ - Septations, internal debris
+ - Thickened wall
+ - ± calcification
+- ### Nonvascular Interventions
+
+
+ - Cyst aspiration may be helpful in confirming infected or hemorrhagic cyst
+- ### Imaging Recommendations
+
+
+ - #### Best imaging tool
+
+
+ - US, CT, or MR
+ - #### Protocol advice
+
+
+ - Obtain thin axial CT sections to minimize partial-volume averaging and to facilitate multiplanar reformations
+ - MR test of choice for small cysts with higher attenuation on CT due to volume averaging and concern for metastatic disease
+
+## DIFFERENTIAL DIAGNOSIS
+
+- [Autosomal Dominant Polycystic Disease, Liver](/document/autosomal-dominant-polycystic-live-/c8256fa3-0694-412c-bd0f-8869f336ad90)
+ - Hepatic cysts are multiple, of varying sizes, enlarge and distort liver
+ - Often have contents of complex fluid due to prior hemorrhage
+ - Cysts in other organs (50% have renal polycystic disease) ± family history of polycystic disease
+- [Cystic or Necrotic Metastases](/document/hepatic-metastases-and-lymphoma/248db898-197a-4555-a14d-eef5ca2f8967)
+ - Most common with sarcoma metastases and gastrointestinal stromal tumor (GIST)
+ - Especially likely to resemble cysts after chemotherapy
+ - Enhancing mural nodules, thick septa
+ - Complex contents, more evident on MR/US than CT
+- [Mucinous Cystic Neoplasm of Liver](/document/mucinous-cystic-neoplasm-of-liver/0aea34ce-3322-4284-a6f3-6c79e3359520)
+ - Usually large and solitary mass in older women
+ - Homogeneous, hypodense, water-density mass
+ - Almost always has septations and mural nodularity
+ - Rarely nonseptate; these are difficult to distinguish from cysts
+ - Up to 76% occur in left hepatic lobe (usually segment IV)
+- [Biliary Hamartomas](/document/biliary-hamartoma/1b525344-ad66-4381-9ca9-3fb11172744f)
+ - Multiple, usually all < 15 mm in diameter
+ - Often have fibrous nodules in walls; therefore, echogenic on US
+- ### Ciliated Hepatic Foregut Cyst
+
+
+ - Rare (< 100 cases) cystic mass with potential for development of squamous carcinoma in cyst wall
+ - Appears as simple or multiloculated cyst
+ - Cyst contents usually mucinous (> 90%)
+ - Mucin may cause increased signal on T1WI
+- [Hepatic Cavernous Hemangioma](/document/hepatic-cavernous-hemangioma/b6861694-7bb0-4730-860d-4c78c1cdb38b)
+ - Simulates cyst on T2WI
+ - Other sequences and imaging studies (US, CT, enhanced MR)
+ - Easy distinction from cyst due to enhancement
+- [Biloma](/document/biloma/171c7cd5-66b3-4d4d-9dd7-32300312fb5d)
+ - Usually results from trauma, including prior surgery
+ - Biliary necrosis following liver transplantation often results in biloma
+ - History and comparison with prior imaging usually makes distinction
+- [Hepatic Pyogenic Abscess](/document/hepatic-pyogenic-abscess/c0b88320-bb06-4495-9830-70ea36e6cd9c)
+ - Complex, septate, cystic mass
+ - Heterogeneous contents, > water density
+ - May show mural nodularity and thick, enhancing wall
+- [Hydatid (Echinococcal) Disease](/document/hepatic-hydatid-cyst/2bbda180-2b69-44fa-bd95-393c1531056d)
+ - Large, well-defined, cystic liver mass with numerous peripheral daughter cysts
+ - ± calcification and dilated bile ducts
+ - Imaging complements immunologic testing
+- ### Ciliated Hepatic Foregut Cyst
+
+
+ - Rare; subcapsular; usually segment 4
+ - Increased T2 hyperintensity (usually not as high as simple cyst), T1 hyper- or hypointensity; fluid-fluid layer due to fatty or protein-rich contents
+
+## PATHOLOGY
+
+- ### General Features
+
+
+ - #### Etiology
+
+
+ - Congenital simple hepatic cyst
+ - Defective development of intrahepatic biliary duct
+ - #### Associated abnormalities
+
+
+ - Tuberous sclerosis
+- ### Gross Pathologic & Surgical Features
+
+
+ - Simple hepatic cyst
+ - Cyst wall: ≤ 1 mm thick
+- ### Microscopic Features
+
+
+ - True simple hepatic cyst
+ - Single unilocular cyst with serous fluid
+ - Lined by cuboidal bile duct epithelium
+ - Thin underlying rim of fibrous stroma
+ - No communication with bile ducts
+
+## CLINICAL ISSUES
+
+- ### Presentation
+
+
+ - #### Most common signs/symptoms
+
+
+ - Uncomplicated simple cysts are usually asymptomatic
+ - Complicated cyst
+ - Pain and fever (intracystic hemorrhage or infection)
+ - Large cysts present with symptoms of mass effect
+ - Abdominal pain, jaundice, palpable mass
+ - #### Other signs/symptoms
+
+
+ - Cyst rupture with RUQ pain
+ - Compression of stomach or duodenum → nausea, early satiety
+ - Lab data is normal unless bile ducts are compressed
+ - Diagnosis
+ - Fine-needle aspiration and cytology (rarely necessary)
+- ### Demographics
+
+
+ - #### Age
+
+
+ - Seen in any age group
+ - Many increase slowly in size
+ - #### Sex
+
+
+ - M:F = 1:5
+ - #### Epidemiology
+
+
+ - Prevalence: 5-15% of general population
+- ### Natural History & Prognosis
+
+
+ - Complications: Infection, hemorrhage, rupture (all uncommon)
+ - Large cyst: Symptoms due to compression
+ - Of intrahepatic bile ducts: Jaundice
+ - Of vessels: Varices or Budd-Chiari
+ - Of gastric cardia: Dysphagia, abdominal pain
+- ### Treatment
+
+
+ - Large, symptomatic, infected hepatic cyst
+ - Percutaneous aspiration and sclerotherapy with alcohol
+ - Surgical resection or marsupialization (opening into peritoneal cavity)
+
+## DIAGNOSTIC CHECKLIST
+
+- ### Consider
+
+
+ - Rule out cyst-like hepatic lesions (infection, tumor)
+- ### Image Interpretation Pearls
+
+
+ - Sonography shows cyst morphology better than CT
+ - May show mural nodularity, debris, septa missed by CT
+ - CT: Nonenhancing, well-defined, round, homogeneous water density lesion
+ - Small lesion measuring less than blood density on NECT is probably cyst
+ - Hepatic metastases from GIST
+ - Respond to chemotherapy so well that they simulate simple cysts on follow-up exams
+
+ 0354d2c2-2423-40d5-9c2b-d3a17068259f
+
+## References
+
+## Selected References
+
+1. [Varigonda M et al: The role of diffusion-weighted MRI in correlation with contrast-enhanced MRI and histopathology in the evaluation of focal liver lesions. Cureus. 16(10):e71261, 2024](http://www.ncbi.nlm.nih.gov/pubmed/?term=39525143%5Bpmid%5D)
+1. [Reissis Y et al: Hemorrhagic hepatic cysts: diagnosis and management. Am Surg. 86(3):e127-9, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32223818%5Bpmid%5D)
+1. [Kohno S et al: Imaging findings of hemorrhagic hepatic cysts with enhancing mural nodules. Abdom Radiol (NY). 44(4):1205-12, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30663024%5Bpmid%5D)
+1. [Torbenson MS: Hamartomas and malformations of the liver. Semin Diagn Pathol. 36(1):39-47, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30579648%5Bpmid%5D)
+1. [Mavilia MG et al: Differentiating cystic liver lesions: a review of imaging modalities, diagnosis and management. J Clin Transl Hepatol. 6(2):208-16, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29951366%5Bpmid%5D)
+1. [Ansari-Gilani K et al: Ciliated hepatic foregut cyst: report of three cases and review of imaging features. Gastroenterol Rep (Oxf). 5(1):75-8, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=26126985%5Bpmid%5D)
+1. [Long J et al: Acute Budd-Chiari syndrome due to a simple liver cyst. Ann R Coll Surg Engl. 96(1):109E-11E, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=24417858%5Bpmid%5D)
+1. [Kinjo N et al: Large simple hepatic cysts leading to gastric fundal varices in a noncirrhotic patient. Fukuoka Igaku Zasshi. 104(11):449-55, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=24620641%5Bpmid%5D)
+1. [Fischer PE et al: Laparoscopic management of a giant hepatic cyst with fibrin glue fixation of the omentum. Surg Laparosc Endosc Percutan Tech. 21(5):e273-4, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=22002294%5Bpmid%5D)
+1. [Qiu JG et al: Laparoscopic fenestration vs open fenestration in patients with congenital hepatic cysts: a meta-analysis. World J Gastroenterol. 17(28):3359-65, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=21876626%5Bpmid%5D)
+1. [Goodman MD et al: Laparoscopic excision of a ciliated hepatic foregut cyst. JSLS. 13(1):96-100, 2009](http://www.ncbi.nlm.nih.gov/pubmed/?term=19366552%5Bpmid%5D)
+1. [Veigel MC et al: Fibropolycystic liver disease in children. Pediatr Radiol. 39(4):317-27, 2009](http://www.ncbi.nlm.nih.gov/pubmed/?term=19083218%5Bpmid%5D)
+1. [Fukunaga N et al: Hepatobiliary cystadenoma exhibiting morphologic changes from simple hepatic cyst shown by 11-year follow up imagings. World J Surg Oncol. 6:129, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=19077232%5Bpmid%5D)
+1. [Sharma S et al: Ciliated hepatic foregut cyst: an increasingly diagnosed condition. Hepatobiliary Pancreat Dis Int. 7(6):581-9, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=19073402%5Bpmid%5D)
+1. [Martin DR et al: Imaging of benign and malignant focal liver lesions. Magn Reson Imaging Clin N Am. 9(4):785-802, vi-vii, 2001](http://www.ncbi.nlm.nih.gov/pubmed/?term=11694438%5Bpmid%5D)
+1. [Mortelé KJ et al: Cystic focal liver lesions in the adult: differential CT and MR imaging features. Radiographics. 21(4):895-910, 2001](http://www.ncbi.nlm.nih.gov/pubmed/?term=11452064%5Bpmid%5D)
+1. [Casillas VJ et al: Imaging of nontraumatic hemorrhagic hepatic lesions. Radiographics. 20(2):367-78, 2000](http://www.ncbi.nlm.nih.gov/pubmed/?term=10715337%5Bpmid%5D)
+1. [Horton KM et al: CT and MR imaging of benign hepatic and biliary tumors. Radiographics. 19(2):431-51, 1999](http://www.ncbi.nlm.nih.gov/pubmed/?term=10194789%5Bpmid%5D)
+
+## Differential diagnosis
+
+### Cystic Hepatic Mass
+DDX:85bb9a0b-2d25-457d-a131-20ff07cb552b
+
+### Cystic Liver Lesion
+DDX:c18aa6ea-d21c-4e66-af83-4d4b168dc014
+
+### Focal Liver Lesion With Hemorrhage
+DDX:5e6be44f-07d3-4569-abe3-798d7513fe41
+
+### Multiple Hypodense Liver Lesions
+DDX:5178ae9c-1ea9-4e06-9e8a-91e98d8708f6
+
+### Hyperintense Liver Lesions (T1WI)
+DDX:2efd9ba2-d744-44ac-844f-d706d5cdad85
+
+### Hepatic Mass in a Neonate
+DDX:a4d9d25d-ae2a-486a-9709-10dbb62e0361
+
+### Hypoechoic Liver Mass
+DDX:70fea150-3a7b-4f5c-a8f5-9ecc5c6df6e4
+
+### Multiple Hepatic Masses
+DDX:5a0f58f1-beb9-459d-8246-83d6ddaf76db
+
+## Cases
+
+- {'cases': [{'authors': [{'key': '11951537-5325-4ab3-8914-c6b3eedb3ebb', 'value': 'Bhawan K. Paunipagar, MBBS, MD, DNB'}, {'key': '01bde7cf-c6c0-41b5-bdea-0eb9bdfd785c', 'value': ' Prince of Wales Hospital, HK'}, {'key': '26828c43-b203-40f1-a5c3-02ef9d4f4675', 'value': 'Anil T. Ahuja, MD, FRCR'}], 'caseVersionId': '313d335c-524b-4b03-9bc3-d3a72f73a388', 'description': 'Typical case of hepatic cyst.\n\nGrayscale ultrasound of liver (#1-5) shows multiple cysts (arrow) in both lobes of the liver. The larger cyst appears lobulated and shows septae within. \n\nComment: The multiplicity, appearance may be suspicious for malignancy and hence it is important to exclude presence of any primary tumor, before suggesting the diagnosis of simple hepatic cysts. In this patient there is no known primary and patient was undergoing a routine abdominal sonogram. Tumor markers for certain common tumors were also negative.', 'history': 'Incidental finding.', 'imagePoolId': '4b34720d-1cd9-4f95-b6c4-d778cb34a832', 'name': 'Simple', 'teachingPoint': None, 'demographics': '78 Years old male'}, {'authors': [{'key': '11951537-5325-4ab3-8914-c6b3eedb3ebb', 'value': 'Bhawan K. Paunipagar, MBBS, MD, DNB'}, {'key': '01bde7cf-c6c0-41b5-bdea-0eb9bdfd785c', 'value': ' Prince of Wales Hospital, HK'}, {'key': '26828c43-b203-40f1-a5c3-02ef9d4f4675', 'value': 'Anil T. Ahuja, MD, FRCR'}], 'caseVersionId': '4aff9aa4-c79d-493b-83a3-bca4624a85b4', 'description': 'Typical case of hepatic cyst.\n\nGrayscale ultrasound (#1-2) shows a small liver cyst (arrow) with thin internal septa (curved arrow). Note the cyst is anechoic with imperceptible walls and posterior acoustic enhancement (open arrow).', 'history': 'Incidental finding.', 'imagePoolId': 'afe71ca0-0e02-4c20-8497-aaf3ba426237', 'name': 'Septate', 'teachingPoint': None, 'demographics': '46 Years old male'}, {'authors': [{'key': '11951537-5325-4ab3-8914-c6b3eedb3ebb', 'value': 'Bhawan K. Paunipagar, MBBS, MD, DNB'}, {'key': '01bde7cf-c6c0-41b5-bdea-0eb9bdfd785c', 'value': ' Prince of Wales Hospital, HK'}, {'key': '26828c43-b203-40f1-a5c3-02ef9d4f4675', 'value': 'Anil T. Ahuja, MD, FRCR'}], 'caseVersionId': '91696774-568e-4f60-8922-acddd2b19371', 'description': 'Typical case of multiple hepatic cysts.\n \nGrayscale ultrasound (#1-3) shows multiple thin-walled anechoic cysts (arrows) of varying sizes in both lobes of liver. Note the posterior enhancement (curved arrow). Thin internal septations are present in one of the cysts (open arrow, #3). \n\nComment: Although multiple hepatic cysts are commonly seen, cystic metastases should be ruled out before suggesting a firm diagnosis. Detailed clinical history and reviewing previous imaging studies, if any, are useful.', 'history': 'Incidental finding.', 'imagePoolId': 'dd1fa33e-e775-4a5f-8ced-b340027f33ac', 'name': 'Multiple', 'teachingPoint': None, 'demographics': '45 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '838ae607-3b1f-4702-9f8f-44b69676b5f4', 'description': 'CECT shows multiple water density hepatic lesion with no discernible walls. One of the larger cysts has a thin septum (arrow, #2), but there is no nodularity of the wall.\n\nComments: Simple hepatic cysts are commonly multiple, and this is not necessarily evidence of autosomal dominant polycystic disease, which usually results in many more and larger cysts.\n\nBiliary hamartomas can also cause an appearance of multiple "cysts", but these are rarely larger than 2 cm in diameter and are usually of similar size, unlike in this case.', 'history': 'Incidental finding.', 'imagePoolId': 'b6273fb1-c5e9-4e3e-82fd-6e8b452b55b7', 'name': 'Multiple', 'teachingPoint': None, 'demographics': '76 Years old female'}, {'authors': [{'key': '11951537-5325-4ab3-8914-c6b3eedb3ebb', 'value': 'Bhawan K. Paunipagar, MBBS, MD, DNB'}, {'key': '26828c43-b203-40f1-a5c3-02ef9d4f4675', 'value': 'Anil T. Ahuja, MD, FRCR'}], 'caseVersionId': '6cb9d3a6-e488-4c04-a9f6-852eaaae76bc', 'description': 'Typical case of simple liver cyst.\n\nGrayscale ultrasound of liver (#1-2) shows a simple cyst (arrow), it is anechoic with imperceptible walls and shows posterior acoustic enhancement (open arrow).\n\nComment: Simple cysts are the second most common benign lesions in the liver after hemangiomas.', 'history': 'Incidental finding during a routine abdominal ultrasound.', 'imagePoolId': 'e9bfc0dd-3da3-4e77-ae08-94d15602593b', 'name': 'Simple', 'teachingPoint': None, 'demographics': '65 Years old male'}, {'authors': [{'key': '11951537-5325-4ab3-8914-c6b3eedb3ebb', 'value': 'Bhawan K. Paunipagar, MBBS, MD, DNB'}, {'key': '01bde7cf-c6c0-41b5-bdea-0eb9bdfd785c', 'value': ' Prince of Wales Hospital, HK'}, {'key': '26828c43-b203-40f1-a5c3-02ef9d4f4675', 'value': 'Anil T. Ahuja, MD, FRCR'}], 'caseVersionId': '18893f98-fb77-4312-b443-b8c32218abd6', 'description': 'Typical case of hepatic cyst.\n\nGrayscale (#1-2) and color Doppler (#3) ultrasound images show a simple cyst (arrow) abutting the portal vein (curved arrow, #2,3). On grayscale it appears to be merging with the portal vein, however a realtime color Doppler study (#3) showed it to be separate from the portal vein.', 'history': 'Incidental finding.', 'imagePoolId': '70cd259b-2775-46bb-bdae-67a3b99d6fc6', 'name': 'Small', 'teachingPoint': None, 'demographics': '34 Years old male'}, {'authors': [{'key': '11951537-5325-4ab3-8914-c6b3eedb3ebb', 'value': 'Bhawan K. Paunipagar, MBBS, MD, DNB'}, {'key': '58ab0120-f7a8-436e-ac87-15557e1455a9', 'value': ' KEM Hospital, Mumbai, INDIA'}, {'key': '26828c43-b203-40f1-a5c3-02ef9d4f4675', 'value': 'Anil T. Ahuja, MD, FRCR'}], 'caseVersionId': '364f18da-2988-456f-944a-a7266a79be89', 'description': 'Typical case of hemorrhagic cyst.\n\nGrayscale (#1) and color Doppler (#2-4) ultrasound images of liver show a large, irregularly marginated, complex cyst (arrow). Note the fibrin strands forming septae (open arrows) in the hemorrhagic cyst . Internal echoes representing debris (curved arrow) are also seen. Note the absence of vascularity within the debris, septae and cyst walls (#2-4).', 'history': 'Patient with a known hepatic cyst. Presents with dull aching RUQ pain for a few days.', 'imagePoolId': 'aa1ad7c6-ae8b-4605-8689-53fdd1f78f22', 'name': 'Hemorrhage', 'teachingPoint': None, 'demographics': '53 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'f77d2e33-c677-434a-8729-1b8734d11af4', 'description': 'CECT and MR both show a large cystic hepatic mass that has water density (CT) and intensity (MR) contents. Also evident are at least two thin septa (arrows, #2-5).\n\nComment: The cyst remained stable in size. Because the patient was only mildly symptomatic and because surgical excision was felt to be associated with considerable morbidity, no additional evaluation or therapy was performed.\n\nIt is not unusual to see thin septa in hepatic simple cysts. While there is no absolute diagnostic criterion to distinguish a simple (biliary) cyst from a cystic neoplasm, neoplasms usually demonstrate more complexity of the fluid contents and more septal and wall irregularity.', 'history': 'Elderly woman with right upper quadrant discomfort.', 'imagePoolId': 'b20f9b41-f724-4683-9d8e-b87290b504ed', 'name': 'With septations', 'teachingPoint': None, 'demographics': '75 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'a6ec17a2-f3ec-4633-9ef9-64c3a154ac49', 'description': 'CECT (#1) shows a spherical liver mass with water density, homogeneous contents. No internal debris or wall irregularities are present.\n\nSonography (#2) shows an anechoic mass with accentuated through transmission.\n\nComment: Ultrasonography is an excellent problem-solving test when confirmation is needed for a cystic-appearing mass. In this patient confirmation was not required, but the patient had sonography to further evaluate upper abdominal pain of unknown etiology.', 'history': 'Incidental finding.', 'imagePoolId': '90b3024f-4bb1-4ca1-8f6e-d00ce6877832', 'name': 'Classic', 'teachingPoint': None, 'demographics': '79 Years old female'}, {'authors': [{'key': '11951537-5325-4ab3-8914-c6b3eedb3ebb', 'value': 'Bhawan K. Paunipagar, MBBS, MD, DNB'}, {'key': '58ab0120-f7a8-436e-ac87-15557e1455a9', 'value': ' KEM Hospital, Mumbai, INDIA'}], 'caseVersionId': '4287a10f-c3e7-4ad2-a6c4-f629433d93bb', 'description': 'Variety of types of hepatic cysts.\n\nGrayscale ultrasound of the liver in different patients shows a variety of appearances of hepatic cysts\n\nA simple hepatic cyst (arrow, #1) is anechoic, well defined, smoothly marginated with imperceptible walls, shows posterior acoustic enhancement. Calcification (curved arrow, #2) may be present in longstanding cysts. The cysts may be solitary large (open arrow, #3) or multiple small or medium sized cysts (open arrows, #4). The cysts may show septae/fibrin strands (open arrows, #5) or debris, fluid level either due to hemorrhage or due to secondary infection (curved arrow, #6).', 'history': 'Collection of cysts with different appearances. Different patients, an image gallery.', 'imagePoolId': '5dbdcf77-4545-4974-baa4-002d6288e4a4', 'name': 'Variety of appearances', 'teachingPoint': None}, {'authors': [{'key': '11951537-5325-4ab3-8914-c6b3eedb3ebb', 'value': 'Bhawan K. Paunipagar, MBBS, MD, DNB'}, {'key': '01bde7cf-c6c0-41b5-bdea-0eb9bdfd785c', 'value': ' Prince of Wales Hospital, HK'}, {'key': '26828c43-b203-40f1-a5c3-02ef9d4f4675', 'value': 'Anil T. Ahuja, MD, FRCR'}], 'caseVersionId': '4677f9b9-0838-42e7-9050-a02809ca0b17', 'description': 'Typical case of hepatic cyst.\n\nGrayscale (#1,2) and power Doppler (#3) ultrasound images show a simple cyst (curved arrow) in the caudate lobe of the liver. Note the posterior acoustic enhancement (open arrow, #1). There is no internal debris, septation or abnormal vascularity. Features of a simple hepatic cyst.', 'history': 'Incidental finding.', 'imagePoolId': 'f0826827-d15d-4544-b308-8ea2b9995a79', 'name': 'Small', 'teachingPoint': None, 'demographics': '43 Years old male'}], 'caseType': 'typical', 'name': 'TYPICAL'}
+- {'cases': [{'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '7b1218fc-14aa-486e-b424-aead131f3914', 'description': 'CT shows a large cyst with signs of rupture. The cyst is well-circumscribed with a thin wall, characteristic of a simple cyst. However, within the cyst is a heterogeneous focus of higher attenuation (open arrow, #2, 3), suggestive of acute hemorrhage. Also noted is ascites (curved arrow, #4) that had an attenuation of about 15 HU, suggesting intraperitoneal rupture of the cyst.\n\nComment: These findings were confirmed at surgery, and the cyst was resected.', 'history': 'Elderly woman with chronic and acute right upper quadrant pain.', 'imagePoolId': 'bf6ac869-66c4-4874-a7e2-9282c41308e5', 'name': 'Large, with bleed and rupture', 'teachingPoint': None, 'demographics': '69 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '82ecb4b0-73a7-47f5-bb17-8a3835eef023', 'description': 'CT (#1-5) shows multiple large simple cysts. These have water density contents with no enhancement, and the walls are thin and smooth. On one axial section the walls of one cyst appear indistinct (arrow, #2), but this is due to partial volume averaging, as evidenced by the sharply defined walls of the same cyst on coronal reformations.\n\nBecause of the symptoms, the larger cysts were either opened ("marsupialized") into the peritoneal cavity or resected, with the resected specimen seen in image #6.', 'history': 'Upper abdominal discomfort.', 'imagePoolId': '4a7b872b-fd6b-47aa-b173-182c8f20a540', 'name': 'Multiple, symptomatic; with pathology', 'teachingPoint': None, 'demographics': '68 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '55140925-7cda-44cb-a3d4-3be6319da0fb', 'description': 'CT images (#1-5) show multiple hepatic cysts of varying size. Most are typical simple cysts, with water density, nonenhancing contents and sharp, thin walls. The largest cyst, however, has a shaggy border and higher density contents, though with no enhancing contents or mural nodularity. The hyperdense hemorrhage that settles in the dependent porton of the cyst is most evident on the NECT (curved arrow, #1).', 'history': 'Right upper quadrant discomfort.', 'imagePoolId': '8ff3a9c4-7266-48af-a16c-fac4fff25a77', 'name': 'With substantial acute hemorrhage; CT', 'teachingPoint': None, 'demographics': '45 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '129f101f-b2f2-455c-96ab-757a47147226', 'description': 'CTs show multiple hepatic masses that have subtle but important differences in appearance. Multiple hepatic cysts (curved arrows, #1-3) are water density and homogeneous, while multiple foci of epithelioid hemangioendothelioma (arrows, #1-3) are heterogeneous, enhancing, and some are associated with retraction of the overlying hepatic capsule (#3). \n\nComment: Multiplicity, peripheral location, confluence and capsular retraction are all classic features of EHE.', 'history': 'Weight loss and right upper quadrant discomfort.', 'imagePoolId': 'f5fa18b3-14ca-402b-a43c-7a4d5f33ae10', 'name': 'EHE and cysts; potential misinterpretation', 'teachingPoint': None, 'demographics': '53 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '15751b6c-0191-433c-8e1f-e700727b3c44', 'description': 'A T1 contrast-enhanced MR image (#1) shows a complex, loculated cystic mass in the right hepatic lobe. The lesion contents are hypointense, as expected for simple fluid. However, there is visible thickening of the walls of the cystic mass (arrows). T2WI in the axial (#2) and coronal (#3) planes show the lobulated, mass, containing homogeneously hyperintense fluid, typical of a cyst.\n\nComment: The thickened cyst walls presumably resulted from a prior episode of intracystic infection or bleeding.\n\nSome neoplasms, especially biliary cystadenoma and treated metastases from gastrointestinal stroma tumors (GIST) may have a similar appearance, but usually demonstrate more complexity of the fluid contents and walls.', 'history': None, 'imagePoolId': '2b6ac176-44b0-4bce-ad64-ab4842d8c4e5', 'name': 'With thick wall', 'teachingPoint': None}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'a0bfb0d3-c1e5-4557-858a-396019984f9b', 'description': 'At least 2 large masses are seen in the liver, with the larger having contents that are bright on both T1 (arrow, #1) and T2WI, (arrows, #2-5) indicative of hemorrhage. The cyst contents are not as bright on T2WI as they are in the nonhemorrhagic, smaller cyst. The hemorrhage also accounts for the mural irregularity, septa, and debris level (curved arrow, #2) seen within this cyst. For comparison, the smaller cyst has typical features of "simple" fluid contents, being very dark on T1WI (open arrow, #1) and bright on T2WI (open arrows, # 3-5).', 'history': 'Right upper quadrant discomfort.\n', 'imagePoolId': '9ad682e7-f372-4788-a9f3-943935cd7033', 'name': 'Large hemorrhagic & simple cysts; MR', 'teachingPoint': None, 'demographics': '70 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '3d792e73-23ca-4154-aac1-87fd2a5e75b5', 'description': 'MR shows a large hepatic mass that has hyperintense fluid contents. There is some heterogeneity of the contents and settling of particulate material to the dependent position of the cyst, findings characteristic of hemorrhage.', 'history': 'Middle-aged woman with acute abdominal pain; receiving Coumadin for pulmonary embolism.', 'imagePoolId': '5724ae0e-006c-43a1-9309-d30b0adaa299', 'name': 'With acute hemorrhage', 'teachingPoint': None, 'demographics': '56 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'ba5986dd-ec3d-4614-88b3-46688a97a064', 'description': 'CTs show several water density hepatic cysts, including an unusually large one (arrows, #1-2), that produced mass effect sufficient to cause biliary obstruction (curved arrows, #1, 3). Two of the cysts are seen on the ultrasound image (arrows, #4) as well.', 'history': 'Right upper quadrant discomfort and elevated serum alkaline phosphatase.', 'imagePoolId': '2f513786-10fe-4bee-b41a-7c59dee931de', 'name': 'Large, with biliary obstruction', 'teachingPoint': None, 'demographics': '45 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'e851463c-27fd-4fbf-818b-4b99af4ab712', 'description': 'Four grayscale sonographic images (#1-4) show a large hepatic cyst (arrows) that contains internal septa (curved arrows). Accentuated through transmission (open arrow, #4) confirms the cystic nature of the lesion. CECT was recommended for further evaluation.\n\nAxial (#5-9) and coronal (#10-16) CECT shows the same large cyst in segments 7 & 8 (arrows, #5-7), along with the internal septa (curved arrow, #5). However, axial CT clearly shows other cysts (curved arrows, #6-9), including a large, septate cyst in segments 5 & 6 that has a similar appearance to the large cyst in segments 7 & 8. Coronal reformations of the CECT (#10-16) clearly show the large, septate cyst (arrows, #11-16) as well as the other smaller cysts (curved arrows, #10-13).\n\nComment: By imaging criteria alone, the large lesion identified by sonography and confirmed on CECT (in segments 7 & 8) could not be differentiated from a biliary cystadenoma. However, the presence of other similar, though smaller, cysts is reassuring that these are all simple cysts, because cystadenomas are almost always solitary lesions. In addition, cystadenomas occur almost exclusively in women, and this patient is a man.', 'history': 'Right upper quadrant discomfort.', 'imagePoolId': 'b57e72c6-7bd9-4752-9ff6-2aa9a9631202', 'name': 'Septate cyst mimicking cystadenoma', 'teachingPoint': None, 'demographics': '72 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '5e648e52-5aa1-4594-8ba5-554cf8ab9ad6', 'description': 'CT shows one large, and many smaller hepatic cysts. The largest cyst (arrow, #1) is almost 15 cm in diameter, and displaces large hepatic vessels. Bile ducts within the left lobe (curved arrow, #3, 4) are dilated due to extrinsic compression of the left main duct.\n\nComment: The mass was resected and confirmed as a simple hepatic cyst.', 'history': 'Middle-aged woman with right upper quadrant discomfort.', 'imagePoolId': '8743e4cc-a24e-4be7-8d3d-9a595e35d2f7', 'name': 'Huge, causing biliary obstruction', 'teachingPoint': None, 'demographics': '45 Years old female'}], 'caseType': 'variant', 'name': 'VARIANT'}
+
+
+## Images
+
+
+### Selected Images
+
+
+*Axial CECT shows a spherical hepatic mass with water density and homogeneous contents. No internal debris or wall irregularities are present. This is a classic simple cyst.*
+
+
+*Ultrasound in the same patient shows an anechoic mass with accentuated through transmission . Either CT or US would have been sufficient to establish the diagnosis in this patient.*
+
+
+*Axial T1WI MR shows a large, cystic hepatic mass that has homogeneous low intensity and several thin septa .*
+
+
+*Coronal T2WI MR shows uniform high intensity and septa . The cyst has remained stable for years, and no other evaluation or intervention was performed.*
+
+
+*Axial 5-mm thick CECT in a 68-year-old woman with upper abdominal discomfort shows one of multiple large simple cysts ; the cyst has water-attenuation contents and a thin, smooth wall.*
+
+![Axial CECT in the same patient shows indistinct walls for one of the cysts , but this is due to partial-volume averaging [as confirmed on the coronal reformatted images (not shown)].](images/app.statdx.com_image_thumbnail_2b46d407-616e-4111-9a27-fd7e02fd3d60_annotated_true_size_900_quality_90_db6434ae6155b77e96325d51f9f51ff64fd3222b.jpg)
+*Axial CECT in the same patient shows indistinct walls for one of the cysts , but this is due to partial-volume averaging [as confirmed on the coronal reformatted images (not shown)].*
+
+
+*Axial CECT in the same patient shows mild lobulation or septation of one of the cysts .*
+
+
+*Due to symptoms, the larger cysts in the same case were either opened (marsupialized) into the peritoneal cavity or resected. Note the smooth, translucent nature of the exophytic portion of the cyst wall of the excised cyst.*
+
+
+*Two masses are seen in the liver of a 70-year-old woman with RUQ pain, with the larger cyst having bright contents on T1WI, whereas the smaller cyst's contents are low in signal.*
+
+
+*Axial T2WI MR in the same patient shows very bright, uniform signal within the smaller (simple) cyst , while the larger cyst's contents are more heterogeneous with mural irregularity and debris evident . Aspiration of the larger cyst yielded hemorrhagic fluid with no sign of infection or neoplasm.*
+
+
+*Axial T1WI C+ MR shows a complex cystic mass in the right hepatic lobe. The lesion contents are hypointense, as expected for simple fluid. However, there is visible thickening of the walls of the cystic mass .*
+
+
+*Axial T2WI MR in the same patient shows high-intensity simple fluid within the cyst. There was no history of malignancy, and the cyst fluid was clear on aspiration. The wall thickening is presumably the result of prior infection or hemorrhage within the cyst.*
+
+
+*Axial CECT in a 69-year-old woman with RUQ pain shows a well-circumscribed cyst with a thin wall.*
+
+
+*Axial CECT in the same patient shows a heterogeneous focus of higher attenuation within the cyst, suggestive of acute hemorrhage.*
+
+
+*Axial CECT in the same patient shows more of the intracystic hemorrhage .*
+
+
+*Axial CECT in the same patient shows ascites that had an attenuation of ~ 15 HU, suggesting intraperitoneal rupture of the cyst. These findings were confirmed at surgery, and the cyst was resected.*
+
+
+*Axial NECT in a 45-year-old man with RUQ discomfort shows several hepatic cysts with the largest having hyperdense material settling in a dependent position.*
+
+
+*Axial CECT in the same patient shows no enhancement of the clot within the cyst. Without the NECT for comparison, it would be easy to misinterpret the clot as a mural nodularity or tumor.*
+
+
+*Axial T2WI MR in a 19-year-old woman with metastatic chondrosarcoma shows multiple cystic lesions in the liver that are centrally fluid bright with somewhat gray signal in the periphery.*
+
+
+*ADC map in the same patient shows diffusion restriction in the periphery of the lesion only.*
+
+
+*Axial T1WI FS precontrast MR in the same patient shows multiple lobulated, hypointense lesions .*
+
+
+*Axial T1WI C+ FS MR in the same patient shows multiple cystic lesions with a peripheral rim of enhancement that corresponds to the area of diffusion restriction . These features distinguish metastatic disease from a simple cyst.*
+
+
+*Ultrasound in a 72-year-old man with vague upper abdominal discomfort shows a large, septate , cystic hepatic mass with accentuated through transmission .*
+
+
+*Axial CECT in the same patient shows the septate cyst but also shows several smaller cysts .*
+
+
+*CT reformation (same patient) shows the largest septate cyst and numerous renal cysts. By imaging criteria alone, the large lesion identified by US and CT could not be differentiated from a hepatic mucinous cystic neoplasm (MCN). However, MCN of liver are usually solitary, mostly in left lobe, and occur almost exclusively in women, whereas this patient is a man.*
+
+
+*Axial CECT in a patient with autosomal dominant polycystic liver disease (ADPLD) shows innumerable hepatic cysts, though no renal cysts.*
+
+
+*Axial T2WI MR in a patient with newly diagnosed pancreatic ductal adenocarcinoma shows multiple fluid intensity lesions , which can be mistaken for simple cysts.*
+
+
+*Axial T1WI C+ MR in the same patient shows rim enhancement around the lesions . Biopsy showed metastatic, poorly differentiated pancreatic adenocarcinoma.*
+
+
+*Axial CECT shows 1 large and many smaller hepatic cysts in this 45-year-old woman with RUQ discomfort. The largest cyst is almost 15 cm in diameter and displaces hepatic vessels. Bile ducts within the left lobe are dilated due to extrinsic compression of the left main duct.*
+
+
+*Axial CECT in the same patient shows more of the obstructed bile ducts . The mass was resected and confirmed as a simple hepatic cyst.*
+
+
+*Axial CECT shows innumerable small, cystic lesions throughout the liver, ranging in size from 2-15 mm. Close attention shows that the lesions are often not perfectly spherical, and many have visible nodular enhancement within their walls.*
+
+
+*Ultrasound in the same patient on the same day shows only the lesions > 10 mm as cystic structures , whereas the smaller lesions are actually hyperechoic to background liver. This is the classic appearance of biliary hamartomas.*
+
+
+*Axial CECT shows multiple hepatic masses that have important differences in appearance. Multiple hepatic cysts are water density and homogeneous, whereas multiple foci of tumor are heterogeneous and enhancing compared with NECT images.*
+
+
+*Axial T2WI MR shows an enlarged liver with numerous large and small cysts of differing intensities in a patient with ADPLD. Cysts with high-intensity fluid also have internal septa and are the result of internal hemorrhage. Others have simple fluid .*
+
+
+### Additional Images
+
+
+*Axial CECT shows multiple hypodense liver lesions. The largest lesion is sharply defined with a ROI of 2 HU, while the smaller lesions are too small to characterize with confidence.*
+
+
+*Sagittal ultrasound shows an anechoic lesion with no visible wall. Note the through transmission of sound .*
+
+
+*Axial CECT shows multiple hepatic cysts of varying size with water density and no enhancement.*
+
+
+*Sagittal ultrasound shows anechoic lesions with thin walls, through transmission, and no mural nodularity.*
+
+
+*Axial CECT shows multiple simple cysts. The smaller cysts appear of higher water density due to partial-volume averaging.*
+
+
+*Axial T2WI MR shows a large and very hyperintense hepatic cyst with no mural nodularity or septations.*
+
+
+*Axial CECT following blunt trauma shows peripheral water density contents that have ruptured through the capsule of the liver. Higher density hemorrhage is present in the dependent aspect of the cyst.*
+
+
+*Axial CECT shows multiple water-density hepatic lesions with no discernible walls.*
+
+
+*Axial CECT in the same patient shows that one of the larger cysts has a thin septum . Simple hepatic cysts are commonly multiple, and this is not necessarily evidence of ADPLD, which usually results in many more and larger cysts. Biliary hamartomas can also cause an appearance of multiple cysts, but these are rarely > 15 mm.*
+
diff --git a/docs_md/articles/hepatic-metastases-and-lymphoma_248db898-197a-4555-a14d-eef5ca2f8967.md b/docs_md/articles/hepatic-metastases-and-lymphoma_248db898-197a-4555-a14d-eef5ca2f8967.md
new file mode 100644
index 0000000..dd3a7ae
--- /dev/null
+++ b/docs_md/articles/hepatic-metastases-and-lymphoma_248db898-197a-4555-a14d-eef5ca2f8967.md
@@ -0,0 +1,651 @@
+---
+title: "Hepatic Metastases and Lymphoma"
+docid: "248db898-197a-4555-a14d-eef5ca2f8967"
+authors:
+ - key: "6c5a9e0e-9dea-461b-9ad4-c00f5c4c2bbf"
+ value: "Atif Zaheer, MD, FSAR"
+ - key: "e987d3d3-1206-48d6-824b-3347c2968855"
+ value: "Michael P. Federle, MD, FACR"
+breadcrumbs:
+ -
+ name: "Gastrointestinal"
+ slug: "gastrointestinal"
+ treeNodeId: "992c2a4d-e0c4-4b82-be00-a05f5f19e3be"
+ -
+ name: "Diagnosis"
+ slug: "diagnosis"
+ treeNodeId: "65118aca-7db6-4b7c-becd-30be67d24e37"
+ -
+ name: "Liver"
+ slug: "liver"
+ treeNodeId: "3a84cf33-306e-40bb-9947-975013d43188"
+ -
+ name: "Malignant Neoplasms"
+ slug: "malignant-neoplasms"
+ treeNodeId: "2eb8f05b-a5a6-4ba9-b83e-d56553acbdcd"
+ -
+ name: "Hepatic Metastases and Lymphoma"
+ slug: "hepatic-metastases-and-lymphoma"
+ treeNodeId: null
+category: "Gastrointestinal"
+documentVersionId: "95289286-9a28-49a4-8fdf-7ff7691ce29a"
+imageCount: 45
+lastUpdated: "04/03/25"
+pageDescription: "Hepatic Metastases and Lymphoma"
+pageKeywords: "Gastrointestinal, Diagnosis, Liver, Malignant Neoplasms, Hepatic Metastases and Lymphoma"
+pageTitle: "Hepatic Metastases and Lymphoma | STATdx"
+enhancedTitle: "Hepatic Metastases and Lymphoma"
+type: "DX"
+references: true
+ddx: true
+anatomy:
+ - "{'authors': 'Siva P. Raman, MD', 'bookmarked': False, 'bookmarkUrl': '/document/bookmark/e4fdb09c-d20f-407d-b563-499124541261', 'category': 'Gastrointestinal', 'compareUrl': '/compare/document/e4fdb09c-d20f-407d-b563-499124541261/related-anatomy/treeNode?subContext=Liver', 'documentId': 'e4fdb09c-d20f-407d-b563-499124541261', 'documentType': 'ANATOMY', 'documentUrl': '/document/liver/e4fdb09c-d20f-407d-b563-499124541261', 'enhancedTitle': 'Liver', 'entryDate': '06/27/23', 'imageCount': 114, 'imageUrl': '/image/thumbnail/da574c8c-5d46-46c2-ad9e-75150aa38a0a?size=174&quality=85', 'inCompareCart': False, 'rank': 1, 'referenceCount': 8, 'showCompareButton': False, 'title': 'Liver'}"
+ - "{'authors': 'Aya Kamaya, MD, FSRU, FSAR', 'bookmarked': False, 'bookmarkUrl': '/document/bookmark/236fb145-0c29-4362-be57-06401bf337aa', 'category': 'Ultrasound', 'compareUrl': '/compare/document/236fb145-0c29-4362-be57-06401bf337aa/related-anatomy/treeNode?subContext=Liver', 'documentId': '236fb145-0c29-4362-be57-06401bf337aa', 'documentType': 'ANATOMY', 'documentUrl': '/document/liver/236fb145-0c29-4362-be57-06401bf337aa', 'enhancedTitle': 'Liver', 'entryDate': '05/06/24', 'imageCount': 51, 'imageUrl': '/image/thumbnail/d66e35e7-05f2-4a4d-9ae4-6d913a04de28?size=174&quality=85', 'inCompareCart': False, 'rank': 2, 'referenceCount': 11, 'showCompareButton': False, 'title': 'Liver'}"
+cases: 2
+breadcrumbs:
+ - "Gastrointestinal"
+ - "Diagnosis"
+ - "Liver"
+ - "Malignant Neoplasms"
+ - "Hepatic Metastases and Lymphoma"
+---
+## KEY FACTS
+
+- ### Imaging
+
+
+ - Hepatic lymphoma
+ - Diffuse infiltration and low density on NECT
+ - Multiple well-defined, homogeneous, low-density (CECT) or high-intensity (T2WI) masses
+ - Vascular or biliary encasement by periportal hepatic mass without vascular occlusion or thrombosis
+ - Liver metastases
+ - Hypovascular metastases: Low-density center with peripheral rim or target-like enhancement
+ - Hypervascular metastases: Hyperdense (intense) on arterial-phase CECT or CEMR
+ - Colon cancer comprises 50% of cases of metastatic cancer
+ - Cystic metastases (< 20 HU)
+ - Fluid levels, debris, mural nodules
+ - Liver-specific MR contrast agents (e.g., gadoxetate)
+ - Metastases: Hypointense lesions made more apparent compared with bright enhancement of liver on delayed-phase imaging
+ - CECT is usually best as whole-body screening test
+ - Even better if combined as PET/CT
+ - Metastases and lymphoma are usually FDG-avid masses within liver
+ - Decision for thermal ablation or surgical resection
+ - May require most sensitive tests (gadoxetate-enhanced MR, PET/CT, or intraoperative US)
+- ### Top Differential Diagnoses
+
+
+ - Multifocal fatty infiltration (steatosis)
+ - Multiple benign masses
+ - Multifocal hepatocellular carcinoma or cholangiocarcinoma
+- ### Diagnostic Checklist
+
+
+ - In absence of known primary tumor or other metastases
+ - Hepatic lesions that are "too small to characterize" rarely represent metastases
+ - Lesions that are lower than blood density on NECT rarely represent metastases
+
+## TERMINOLOGY
+
+- ### Definitions
+
+
+ - Lymphoma: Neoplasm of lymphoid tissues
+ - Metastases: Malignant spread of neoplasm to hepatic parenchyma
+
+## IMAGING
+
+- ### General Features
+
+
+ - #### Best diagnostic clue
+
+
+ - Lymphoma: Lobulated, low-density, hypovascular masses
+ - Metastases: Multiple heterogeneous, spherical lesions scattered throughout liver
+ - #### Location
+
+
+ - Lymphoma (Hodgkin disease and non-Hodgkin lymphoma) favors periportal areas due to high content of lymphatic tissue
+ - #### Size
+
+
+ - Variable; few mm to > 10 cm
+ - #### Morphology
+
+
+ - Usually spherical
+ - Key concepts
+ - Hepatic lymphoma
+ - Primary (rare), mainly large B-cell non-Hodgkin lymphoma (NHL)
+ - Secondary (more common): Seen in > 50% of patients with Hodgkin disease (HD) or NHL
+ - High-risk groups: Transplant recipients and AIDS patients
+ - Types of hepatic lymphoma: NHL > HD
+ - Liver metastases
+ - Most common malignant tumor of liver
+ - Compared to primary malignant tumors (18:1)
+ - Liver is 2nd only to regional lymph nodes as site of metastatic disease
+ - Autopsy studies reveal 55% of oncology patients have liver metastases
+ - Colon cancer comprises 50% of cases of metastatic cancer
+- ### CT Findings
+
+
+ - #### NECT
+
+
+ - Lymphoma
+ - Diffuse infiltration: Indistinguishable from normal liver or steatosis
+ - Metastases
+ - Isodense, hypodense, or hyperdense (melanin or calcification)
+ - #### CECT
+
+
+ - Lymphoma
+ - Diffuse infiltration and low density
+ - Primary: Solitary in 60%; well-defined, homogeneous, low-density masses
+ - Vascular or biliary encasement by periportal hepatic mass without vascular occlusion or thrombosis
+ - Hypo- (most common), patchy, or ring enhancement
+ - Hypovascular metastases
+ - Low-attenuation center with peripheral rim enhancement (e.g., epithelial metastases)
+ - Indicates vascularized viable tumor in periphery and hypovascular or necrotic center
+ - Rim enhancement may also be due to compressed normal parenchyma
+ - Hypervascular metastases
+ - Hyperdense in late arterial-phase images
+ - May have internal necrosis without uniform hyperdense enhancement
+ - Hypo-/isodense on NECT and portal venous phase
+ - Often washout to become hypodense on delayed-phase CECT
+ - Examples: Endocrine (islet cell), carcinoid, thyroid and renal carcinomas, and pheochromocytoma
+ - Cystic metastases (< 20 HU)
+ - Fluid levels, debris, mural nodules
+- ### MR Findings
+
+
+ - #### T1WI
+
+
+ - Lymphoma and metastases: Hypointense
+ - Melanoma metastases: Hyperintense due to melanin
+ - #### T2WI
+
+
+ - Lymphoma: Diffusely hyperintense or hypointense with peripheral rim of hyperintensity
+ - Metastases
+ - Moderate to high signal
+ - Light bulb sign: Very high signal intensity (e.g., cystic and neuroendocrine metastases)
+ - Mimic cysts or hemangiomas but usually with thick wall or fluid level
+ - #### DWI
+
+
+ - Restricted
+ - #### T1WI C+
+
+
+ - Lymphoma: Minimal enhancement, heterogeneous, target-like; no distortion of vasculature or biliary ducts
+ - Hypoenhancing due to absence of hepatocytes on hepatobiliary phase/contrast
+ - Hypovascular metastases
+ - Same pattern of enhancement as CECT
+ - Low signal in center and peripheral rim enhancement
+ - Perilesional enhancement may be tumor vascularity or hepatic edema
+ - Hypervascular metastases
+ - Hyperintense enhancement on arterial phase
+ - Hepatobiliary contrast agents [e.g., gadoxetate (Eovist, Primovist)]
+ - On delayed scans, normal liver is brightly enhanced
+ - Metastases are more conspicuous as hypointense focal lesions
+ - Most sensitive, but not specific, imaging test for determining presence and number of metastases
+- ### Ultrasonographic Findings
+
+
+ - #### Grayscale ultrasound
+
+
+ - Hepatic lymphoma
+ - Multiple well-defined, hypoechoic lesions
+ - Diffuse form: May detect innumerable subcentimeter hypoechoic foci; otherwise indistinguishable from normal or fatty liver
+ - Hypoechoic metastases; usually from hypovascular tumors
+ - Hyperechoic metastases
+ - GI tract malignancy
+ - Vascular metastases
+ - Bull's-eye or target metastatic lesions
+ - Alternating layers of hyper- and hypoechoic tissue
+ - Solid mass with hypoechoic rim or halo
+ - Usually from aggressive primary tumors
+ - Cystic metastases; almost all show complex walls and contents
+ - Calcified metastases; markedly echogenic with acoustic shadowing
+- ### Nuclear Medicine Findings
+
+
+ - #### PET
+
+
+ - Lymphoma and metastases
+ - FDG-18-avid focal lesions
+ - Excellent staging tool for lymphoma and metastases
+ - High metabolic activity of liver may obscure some lesions
+- ### Imaging Recommendations
+
+
+ - #### Best imaging tool
+
+
+ - Metaanalysis of sensitivity for detection of colorectal metastases
+ - Per patient basis
+ - CECT: 75%
+ - MR: 76% (much better if gadoxetate is used, up to 96%); MR better for characterization of lesions
+ - PET: 90-95%
+ - Per lesion basis (all modalities have lower but similar sensitivity)
+ - All do better for lesions > 1.5 cm
+ - Gadoxetate-enhanced MR much better than CT for lesions < 1.5 cm
+ - CECT is usually best as whole-body screening test
+ - Even better if combined as PET/CT
+ - Decision for thermal ablation or surgical resection
+ - May require most sensitive tests (gadoxetate-enhanced MR, PET/CT, or intraoperative US)
+ - #### Protocol advice
+
+
+ - When to obtain biphasic (arterial- and venous-phase) CT
+ - Known or suspected hypervascular primary tumor
+ - All endocrine tumors (e.g., thyroid, carcinoid, neuroendocrine pancreas, pheochromocytoma), renal cell carcinoma
+ - Some sarcomas, breast cancer, and melanoma metastases are best seen on arterial/biphasic CT scans
+
+## DIFFERENTIAL DIAGNOSIS
+
+- [Multiple Hepatic Cysts](/document/hepatic-cyst/e525e5da-75e8-432c-b398-cb3d18e97771)
+ - No peripheral rim or central enhancement
+ - May have increased density or intensity due to prior bleed or infection (e.g., polycystic liver)
+ - No mural nodules, debris, or enhancement
+- [Multifocal Fatty Infiltration (Steatosis)](/document/steatosis-and-steatohepatitis/de725ab5-ee7d-4629-85f7-4b5bb6ca13b9)
+ - Focal signal dropout on opposed-phase T1 GRE MR
+ - Vessels course through "lesions" without disruption
+ - Periligamentous, perivascular distribution
+- [Multiple Hemangiomas](/document/hepatic-cavernous-hemangioma/b6861694-7bb0-4730-860d-4c78c1cdb38b)
+ - Typical peripheral, nodular, discontinuous enhancement on CECT or CEMR
+ - Isodense with blood vessels on NECT and CECT
+ - Markedly hyperintense on T2WI
+- ### Multifocal Hepatocellular Carcinoma or Cholangiocarcinoma
+
+
+ - Hepatocellular carcinoma (HCC): Cirrhotic liver, vascular invasion
+ - Cholangiocarcinoma (CC): Capsular retraction, delayed enhancement
+- [Multiple Liver Abscesses](/document/hepatic-pyogenic-abscess/c0b88320-bb06-4495-9830-70ea36e6cd9c)
+ - Cluster sign on CT for pyogenic abscesses
+ - Double-target sign
+ - Often with atelectasis and right pleural effusion
+
+## PATHOLOGY
+
+- ### General Features
+
+
+ - #### Etiology
+
+
+ - Hypovascular liver metastases, etiology
+ - Lung, GI tract, pancreas, and most breast cancers
+ - Lymphoma, bladder, and uterine malignancy
+ - Hypervascular liver metastases, etiology
+ - Endocrine tumors, renal and thyroid cancers
+ - Some breast cancers, sarcomas, and melanomas
+ - #### Associated abnormalities
+
+
+ - Metastases: Check for extrahepatic primary tumor
+ - Lymphoma: High-risk groups include patients with AIDS, post transplant, hepatitis C, Epstein-Barr virus infection, autoimmune disease
+- ### Staging, Grading, & Classification
+
+
+ - Liver metastases indicate stage IV tumor
+- ### Gross Pathologic & Surgical Features
+
+
+ - Lymphoma: Miliary, nodular, or diffuse form
+ - Metastases vary in size, consistency, and vascularity
+ - Nodular, infiltrative, expansile, or miliary
+- ### Microscopic Features
+
+
+ - HD
+ - Typical Reed-Sternberg cells
+ - NHL
+ - Follicular, small, cleaved cells (most common)
+ - Small, noncleaved cells [Burkitt lymphoma (rare)]
+
+## CLINICAL ISSUES
+
+- ### Presentation
+
+
+ - #### Most common signs/symptoms
+
+
+ - Asymptomatic, RUQ pain, tender hepatomegaly
+ - Weight loss, jaundice, or ascites
+ - Lab data: Elevated liver function tests; normal in 25-50% of patients
+ - Diagnosis: Imaging, core biopsy, and fine-needle aspiration
+- ### Demographics
+
+
+ - #### Age
+
+
+ - Usually middle aged or older
+ - #### Epidemiology
+
+
+ - > 50,000 deaths per year in USA due to liver metastases from colorectal cancer alone
+- ### Natural History & Prognosis
+
+
+ - Depends on primary tumor site
+ - 20-40% have good 5-year survival rate if resectable
+ - Resection plus chemotherapy offers excellent 5- and 10-year survival in selected patients
+- ### Treatment
+
+
+ - Resection or ablation for colorectal liver metastases
+ - Chemo- or radioembolization for hypervascular (carcinoid or endocrine) metastases
+ - Chemotherapy (oral or IV) for all others
+
+## DIAGNOSTIC CHECKLIST
+
+- ### Consider
+
+
+ - Consider lymphoma: Liver mass in relatively younger patient age (< 40 years), absence of known primary malignancy, fever of unknown origin ± night sweats, abnormal bone marrow biopsy
+ - Multifocal, benign lesions (cysts, hemangiomas, &/or focal nodular hyperplasia)
+- ### Image Interpretation Pearls
+
+
+ - In absence of known primary tumor or other metastases
+ - Hepatic lesions that are "too small to characterize" rarely represent metastases
+ - Lesions that are lower than blood density on NECT rarely represent metastases
+
+ ef806d75-f2e7-4c69-babb-608a475f61ad
+
+## References
+
+## Selected References
+
+1. [Drzymalski K et al: Multimodality radiologic and pathologic findings in large B-cell lymphoma with hepatic presentation in an unusually young male. Cureus. 16(8):e66847, 2024](http://www.ncbi.nlm.nih.gov/pubmed/?term=39280368%5Bpmid%5D)
+1. [Zhang Y et al: CT and MR imaging characteristics of primary hepatic lymphoma. Discov Oncol. 15(1):428, 2024](http://www.ncbi.nlm.nih.gov/pubmed/?term=39259338%5Bpmid%5D)
+1. [Fujita N et al: Hyperintense liver masses at hepatobiliary phase gadoxetic acid-enhanced MRI: imaging appearances and clinical importance. Radiographics. 40(1):72-94, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=31834849%5Bpmid%5D)
+1. [Ippolito D et al: Diagnostic approach in hepatic lymphoma: radiological imaging findings and literature review. J Cancer Res Clin Oncol. 146(6):1545-58, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32296934%5Bpmid%5D)
+1. [Granata V et al: Diagnostic performance of gadoxetic acid-enhanced liver MRI versus multidetector CT in the assessment of colorectal liver metastases compared to hepatic resection. BMC Gastroenterol. 19(1):129, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=31340755%5Bpmid%5D)
+1. [Arora A et al: Additional radiologic clue to diagnosing hepatic lymphoma. Radiographics. 35(7):2149-50, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=26562243%5Bpmid%5D)
+1. [Nishiwada S et al: Comparison between percutaneous radiofrequency ablation and surgical hepatectomy focusing on local disease control rate for colorectal liver metastases. Hepatogastroenterology. 61(130):436-41, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=24901157%5Bpmid%5D)
+1. [Shin DS et al: Surgical resection of a malignant liver lesion: what the surgeon wants the radiologist to know. AJR Am J Roentgenol. 203(1):W21-33, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=24951226%5Bpmid%5D)
+1. [Abu Hilal M et al: Oncological efficiency analysis of laparoscopic liver resection for primary and metastatic cancer: a single-center UK experience. Arch Surg. 147(1):42-8, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22250111%5Bpmid%5D)
+1. [Park SY et al: Radiofrequency ablation of hepatic metastases after curative resection of extrahepatic cholangiocarcinoma. AJR Am J Roentgenol. 198(1):2, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22109330%5Bpmid%5D)
+1. [Wang CC et al: An update on chemotherapy of colorectal liver metastases. World J Gastroenterol. 18(1):25-33, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22228967%5Bpmid%5D)
+1. [Boonsirikamchai P et al: CT findings of response and recurrence, independent of change in tumor size, in colorectal liver metastasis treated with bevacizumab. AJR Am J Roentgenol. 197(6):W1060-6, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=22109320%5Bpmid%5D)
+1. [Khajanchee YS et al: Hepatic resection vs minimally invasive radiofrequency ablation for the treatment of colorectal liver metastases: a Markov analysis. Arch Surg. 146(12):1416-23, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=22288086%5Bpmid%5D)
+1. [Khan MS et al: Therapeutic management of patients with gastroenteropancreatic neuroendocrine tumours. Endocr Relat Cancer. 18 Suppl 1:S53-74, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=22005115%5Bpmid%5D)
+1. [Misiakos EP et al: Current treatment for colorectal liver metastases. World J Gastroenterol. 17(36):4067-75, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=22039320%5Bpmid%5D)
+1. [Xu LH et al: Imaging diagnosis of colorectal liver metastases. World J Gastroenterol. 17(42):4654-9, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=22180707%5Bpmid%5D)
+1. [Zani S et al: A role for hepatic metastasectomy in stage IV melanoma and breast cancer: reestablishing the surgical modality. Oncology (Williston Park). 25(12):1158-64, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=22229207%5Bpmid%5D)
+1. [Adam R et al: Patients with initially unresectable colorectal liver metastases: is there a possibility of cure?. J Clin Oncol. 27(11):1829-35, 2009](http://www.ncbi.nlm.nih.gov/pubmed/?term=19273699%5Bpmid%5D)
+1. [Mortensen MB et al: Laparoscopic ultrasound-guided biopsy in upper gastrointestinal tract cancer patients. Surg Endosc. 2738-42, 2009](http://www.ncbi.nlm.nih.gov/pubmed/?term=19357914%5Bpmid%5D)
+1. [Bipat S et al: Colorectal liver metastases: CT, MR imaging, and PET for diagnosis--meta-analysis. Radiology. 237(1):123-31, 2005](http://www.ncbi.nlm.nih.gov/pubmed/?term=16100087%5Bpmid%5D)
+
+## Differential diagnosis
+
+### Cystic Hepatic Mass
+DDX:85bb9a0b-2d25-457d-a131-20ff07cb552b
+
+### Cystic Liver Lesion
+DDX:c18aa6ea-d21c-4e66-af83-4d4b168dc014
+
+### Diffuse Liver Disease
+DDX:59f30739-548e-4501-96dc-57e48a5386cb
+
+### Echogenic Liver Mass
+DDX:caf98eea-48d6-4a0f-a747-1c162f945fed
+
+### Fat-Containing Liver Mass
+DDX:1bbbb785-e1e1-4f52-9a37-6ef333c7ec55
+
+### Focal Hepatic Echogenic Lesion ± Acoustic Shadowing
+DDX:6b7939de-9506-4ee2-944d-65766e04e5cf
+
+### Focal Liver Lesion With Hemorrhage
+DDX:5e6be44f-07d3-4569-abe3-798d7513fe41
+
+### Hemoperitoneum
+DDX:552e0b3f-a4c2-4195-a8de-87c32b6fd96b
+
+### High-Attenuation (Hyperdense) Ascites
+DDX:37b0a03f-b726-4b43-9812-45409af23350
+
+### Hyperintense Liver Lesions (T1WI)
+DDX:2efd9ba2-d744-44ac-844f-d706d5cdad85
+
+### Hypoechoic Liver Mass
+DDX:70fea150-3a7b-4f5c-a8f5-9ecc5c6df6e4
+
+### Liver Lesion With Capsule or Halo on MR
+DDX:723cf3ce-66c2-491a-8331-49f5aaf8a054
+
+### Multiple Hepatic Masses
+DDX:5a0f58f1-beb9-459d-8246-83d6ddaf76db
+
+### Multiple Hypodense Liver Lesions
+DDX:5178ae9c-1ea9-4e06-9e8a-91e98d8708f6
+
+### Asymmetric Dilation of Intrahepatic Bile Ducts
+DDX:54bd67f4-bbad-48a9-9baa-96d727b34aef
+
+### Biliary Strictures, Multiple
+DDX:7d85bca2-14b8-4a55-8ba4-ded2672122d6
+
+### Focal Hyperdense Hepatic Mass on Nonenhanced CT
+DDX:482d9968-2c80-4ea1-9562-8dfbabb4e517
+
+### Focal Hyperperfusion Abnormality (THAD or THID)
+DDX:db4385a3-b724-4ad2-91b1-44332d70914f
+
+### Focal Hypervascular Liver Lesion
+DDX:69ce0141-f34e-49d9-a70f-e4da8af391f7
+
+### Hepatic Calcifications
+DDX:325a4527-e4dc-485b-9f89-2cfd5f0a311c
+
+### Hyperechoic Liver, Diffuse
+DDX:b93336e2-9006-4f95-92c1-10276069dcc0
+
+### Liver Lesion Containing Gas
+DDX:fa37a33a-89b1-47a1-88dd-aac411492aaf
+
+### Liver "Mass" With Capsular Retraction
+DDX:6805354c-8246-45dc-aa61-c84f0dab6d16
+
+### Liver Mass With Central or Eccentric Scar
+DDX:75912629-c3e6-4960-9e4d-513fa23779ac
+
+### Mosaic or Patchy Hepatogram
+DDX:1c5f721d-871a-4ce1-858b-5144e4802724
+
+### Multiple Hypointense Liver Lesions (T2WI)
+DDX:eec74ad0-7cc0-49e7-8f1f-1e7608451d94
+
+### Periportal Lucency or Edema
+DDX:be3461de-f44d-4477-8f5b-e62a74b8b691
+
+### Right Upper Quadrant Pain
+DDX:33f29d78-0099-4ee9-85da-d0c70c1e0ce6
+
+### Widened Hepatic Fissures
+DDX:7aaa83d3-f945-4be0-8146-e9f49e381e7e
+
+### Widespread Low Attenuation Within Liver
+DDX:7825b51a-c690-4d68-b456-4d9ae4214f45
+
+### Hepatic Mass With Central Scar
+DDX:cf8a471a-3174-43e2-98a5-dce76a3512e5
+
+### Hepatomegaly
+DDX:fa133894-b0a5-43cf-8b6d-8445f1281374
+
+### Irregular Hepatic Surface
+DDX:f17bee75-f8ce-4073-92b0-c086f86ae808
+
+### Periportal Lesion
+DDX:a8bc808b-8270-46c1-beb4-9c380238e211
+
+### Target Lesions in Liver
+DDX:adbcbcd1-d849-45a5-ba3e-01ac759daca2
+
+## Anatomy
+
+### Liver
+Gastrointestinal/ANATOMY:e4fdb09c-d20f-407d-b563-499124541261
+
+### Liver
+Ultrasound/ANATOMY:236fb145-0c29-4362-be57-06401bf337aa
+
+## Cases
+
+- {'cases': [{'authors': [{'key': '11951537-5325-4ab3-8914-c6b3eedb3ebb', 'value': 'Bhawan K. Paunipagar, MBBS, MD, DNB'}, {'key': '01bde7cf-c6c0-41b5-bdea-0eb9bdfd785c', 'value': ' Prince of Wales Hospital, HK'}, {'key': '26828c43-b203-40f1-a5c3-02ef9d4f4675', 'value': 'Anil T. Ahuja, MD, FRCR'}], 'caseVersionId': '72818b27-a712-4ef8-8146-869bc8939bbc', 'description': 'Typical case of isoechoic liver metastases.\n\nGrayscale transabdominal ultrasound (#1-3) shows diffuse hepatomegaly. There are isoechoic metastases (arrows) in both liver lobes causing mass effect and effacement of the IHBR, intervening portal radicles (open arrow). \n\nThe differential diagnosis includes multifocal hepatocellular carcinoma. \n\nComment: Isoechoic and infiltrating metastases are ill defined and difficult to identify. They can be identified just by their mass effect causing contour and surface irregularity or as displacement/compression of the adjacent intrahepatic vasculature, biliary radicles. Other signs of malignancy may be apparent which include lymphadenopathy, ascites, and peritoneal metastases.', 'history': 'Deranged liver function, patient with known pancreatic cancer, disseminated disease.', 'imagePoolId': 'ca118b93-9e07-4d7e-9d99-a8bc67f8eff5', 'name': 'Isoechoic', 'teachingPoint': None, 'demographics': '70 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '60f9a58a-fb00-46ea-897c-d83da7642433', 'description': "Axial CECT images in the arterial phase show a large, hypervascular pancreatic mass (, Figs. 2-3) and innumerable hypervascular liver metastases (, Figs. 1-3) , some of which demonstrate ring-shaped enhancement patterns. These findings are typical of a malignant islet cell (neuroendocrine) tumor of the pancreas, a glucagonoma in this case.", 'history': 'Patient with hyperglycemia presents with migratory rash on legs.', 'imagePoolId': '74d0909c-5893-42d2-a8a0-4c7616bcecc9', 'name': 'Pancreatic Neuroendocrine Tumor (Glucagonoma) With Hypervascular Primary Tumor and Liver Metastases', 'teachingPoint': 'Primary pancreatic neuroendocrine tumors and their metastases (usually to the liver) are usually avidly hypervascular and are best visualized on arterial-phase or pancreatic-phase images.', 'demographics': '45 Years old male'}, {'authors': [{'key': '11951537-5325-4ab3-8914-c6b3eedb3ebb', 'value': 'Bhawan K. Paunipagar, MBBS, MD, DNB'}, {'key': '01bde7cf-c6c0-41b5-bdea-0eb9bdfd785c', 'value': ' Prince of Wales Hospital, HK'}, {'key': '26828c43-b203-40f1-a5c3-02ef9d4f4675', 'value': 'Anil T. Ahuja, MD, FRCR'}], 'caseVersionId': '4fb1763f-9d8c-4c47-82c1-747fb20b7527', 'description': 'Typical case of echogenic liver metastasis.\n\nGrayscale ultrasound of liver (#1-3) shows typical hyperechoic (arrows) metastases from colonic carcinoma. \n\nComment: The list of differential diagnoses for multiple echogenic liver lesions include hemangiomas, vascular metastases from primary neuroendocrine tumour, choriocarcinoma, melanoma and colon carcinoma.', 'history': 'Patient with known carcinoma colon presented with tender hepatomegaly.', 'imagePoolId': '88c8dc37-0444-4aad-82ec-893a86c9b75f', 'name': 'Echogenic', 'teachingPoint': None, 'demographics': '61 Years old male'}, {'authors': [{'key': '074adeb1-51f1-486e-a476-d495527dca11', 'value': 'Gregory E. Antonio, MD, DRANZCR, FHKCR'}, {'key': '01bde7cf-c6c0-41b5-bdea-0eb9bdfd785c', 'value': ' Prince of Wales Hospital, HK'}, {'key': '26828c43-b203-40f1-a5c3-02ef9d4f4675', 'value': 'Anil T. Ahuja, MD, FRCR'}], 'caseVersionId': '0480b671-d315-4d26-9f69-50f2b0a304e7', 'description': 'Typical case of multiple target lesions in the liver that represent metastases from lung carcinoma.\n\nGrayscale ultrasounds (#1-4) show multiple, liver metastases of varying sizes (arrows) with typical "target" sign (nodule with a thick hypoechoic ring). \n\nComment: The "target" sign is non-specific, however, the multiplicity of the lesions and the history suggests metastatic disease. Target metastases are often seen in patients with lung carcinoma.', 'history': 'Patient was a chronic smoker who was diagnosed with lung carcinoma 2 years ago and treated surgically; recent blood test revealed raised liver enzymes; patient was afebrile.', 'imagePoolId': '30704f1c-8522-4565-9c89-4dbd4a9f43a7', 'name': 'Target lesions', 'teachingPoint': None, 'demographics': '66 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '5a6d91c2-3dba-4525-969d-cd49e9e619a0', 'description': 'Color US (#1) shows multiple spherical liver lesions with a target appearance (open arrow) some with visible blood vessels within (curved arrow). CT (#2,3) shows the same target appearance (arrows) and some dilated intrahepatic bile ducts (curved arrow) due to compression by the metastases.', 'history': 'Weight loss, upper abdominal discomfort.', 'imagePoolId': '0d0cb802-49f9-4805-9f6d-7ef6be3bf109', 'name': 'Classic targets on CT, US, with biliary obstruction', 'teachingPoint': None}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '1a1be892-0055-47ed-98b8-3d61ff548bf0', 'description': 'NECT (#1,2) shows multiple calcified focal liver metastases (arrows). CECT (#3,4) shows additional mets that were not apparent on NECT, but the calcification is less evident.', 'history': 'Colon carcinoma.', 'imagePoolId': 'f4bc7717-50fa-4bbe-8bfe-27f0c0821784', 'name': 'Calcified liver mets, colon cancer', 'teachingPoint': None, 'demographics': '54 Years old male'}, {'authors': [{'key': '11951537-5325-4ab3-8914-c6b3eedb3ebb', 'value': 'Bhawan K. Paunipagar, MBBS, MD, DNB'}, {'key': '01bde7cf-c6c0-41b5-bdea-0eb9bdfd785c', 'value': ' Prince of Wales Hospital, HK'}, {'key': '26828c43-b203-40f1-a5c3-02ef9d4f4675', 'value': 'Anil T. Ahuja, MD, FRCR'}], 'caseVersionId': 'dc048643-e13e-422f-a723-3430fa7e60c2', 'description': 'A case of large hepatic metastasis.\n\nGrayscale ultrasound (#1-3) shows a large fairly homogeneous, hypoechoic hepatic mass (arrows) in the right lobe of liver. Color Doppler (images not included) showed non-specific vascular pattern. Note the distortion and compression of the right portal vein (open arrow). This was subsequently confirmed to be a metastasis.', 'history': 'Patient known with bladder carcinoma. Presented with right upper quadrant swelling and deranged liver function test.', 'imagePoolId': '490d080e-eb76-46ae-a67e-c9fbbc289637', 'name': 'Large', 'teachingPoint': None, 'demographics': '69 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'd2d56e1a-b26e-4606-8678-cb640efc9ab8', 'description': "A series of axial CECT sections taken during the arterial phase of enhancement (#1-10) shows several hypervascular liver metastases (curved arrows, #1-2) and spherical hypervascular peritoneal metastases, particularly within Morison's pouch (open arrows, #2-4). In the right lower quadrant, there is a hypervascular mass arising from the terminal ileum (arrows, #9-10) that thickens its wall and narrows its lumen, causing dilation of a small bowel segment (curved arrow, #10) just upstream from the mass. The cecum and ascending colon (open arrows, #8-10) are fluid-filled but normal in caliber. The hypervascular mass extends into the adjacent small bowel (ileal) mesentery (arrows, #5-8).\n \nCoronal plane 3-D reformations optimally display the distal ileal mass (arrows, #11-13), the desmoplastic response within the mesentery (open arrows, #11-14), and hypervascular metastatic nodes within the mesentery (curved arrow, #11).\n\nComment: This is a classic case of carcinoid tumor, a neuroendocrine malignancy that is arising within the distal ileum, the most common site. The desmoplastic response within the mesentery, and the presence of hypervascular mesenteric, peritoneal, nodal, and liver metastases, are all characteristic features of this neoplasm.", 'history': 'Crampy abdominal pain and episodic flushing.', 'imagePoolId': '8c21eb1a-f340-4774-88e8-efff62520ace', 'name': 'With peritoneal, mesenteric, and liver metastases', 'teachingPoint': None, 'demographics': '54 Years old male'}, {'authors': [{'key': '11951537-5325-4ab3-8914-c6b3eedb3ebb', 'value': 'Bhawan K. Paunipagar, MBBS, MD, DNB'}, {'key': '01bde7cf-c6c0-41b5-bdea-0eb9bdfd785c', 'value': ' Prince of Wales Hospital, HK'}, {'key': '26828c43-b203-40f1-a5c3-02ef9d4f4675', 'value': 'Anil T. Ahuja, MD, FRCR'}], 'caseVersionId': '222b64f0-bbc3-4e14-b8be-3077f68bfc7a', 'description': 'Typical case of hepatic metastases.\n\nGrayscale ultrasound (#1-3) shows multiple, echogenic, liver metastases (arrows). \n\nComment: Metastases from the following tumors tend to be echogenic: GI cancer, renal cell carcinoma, carcinoid, choriocarcinoma, pancreatic islet cell tumors. In children, metastases from neuroblastoma, hepatoblastoma, leukemia, hepatoma, and Wilms tumor may be densely echogenic. Tumors responding to therapy may show increased echogenicity, but more often, they show a reduction in size.', 'history': 'Patient previously treated for breast cancer.', 'imagePoolId': 'b19d24e1-c5fc-4513-8798-7d7a7575462f', 'name': 'Echogenic', 'teachingPoint': None, 'demographics': '47 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'ffedfbd2-474d-4c68-a5d8-b3ba4f3a0903', 'description': 'Arterial phase CT (#1) shows subtle enhancement around the edge of multiple hypodense, hypovascular metastases (arrow). Portal venous phase CT (#2) makes the metastases much more conspicuous, and they have the typical hypodense target appearance of most GI tract adenocarcinomas (arrows). Also noted is dilation of some bile ducts (curved arrow) by the metastases. Ultrasound images (#3-4) show the typical halo or target appearance (arrows) of metastatic adenocarcinoma.', 'history': 'Colon cancer with recent weight loss.', 'imagePoolId': '5b8e12a1-6970-49fa-9f60-a7dc7a43333e', 'name': 'Metastases from colon, typical CT and US', 'teachingPoint': None, 'demographics': '55 Years old male'}, {'authors': [{'key': '11951537-5325-4ab3-8914-c6b3eedb3ebb', 'value': 'Bhawan K. Paunipagar, MBBS, MD, DNB'}, {'key': '26828c43-b203-40f1-a5c3-02ef9d4f4675', 'value': 'Anil T. Ahuja, MD, FRCR'}], 'caseVersionId': 'c8d13e69-2f09-4e28-9eb4-e00ea15b7091', 'description': 'Typical case of multiple liver metastases.\n\nGrayscale ultrasound (#1-3) shows multiple mixed echogenicity liver metastases (arrows). Note there is distortion and compression of the right branch of the portal vein (open arrow, #3).', 'history': 'Patient with adenocarcinoma of unknown origin. Follow up USG showed multiple liver masses', 'imagePoolId': '6c48eec8-4e10-46bf-99a9-ef9d4784720c', 'name': 'Large', 'teachingPoint': None, 'demographics': '45 Years old male'}, {'authors': [{'key': '64470aa4-5429-4786-81fa-be44c86ca020', 'value': 'Kristine S Spinelli, MD'}], 'caseVersionId': '25e5bd73-74e0-4fa2-80d2-fd85f6440cef', 'description': 'CECT of typical hypovascular metastases from melanoma.\n\nMultiple low attenuation metastases are seen in the liver and spleen (#1, 2). Note the lymphadenopathy in the porta hepatis and gastrohepatic region (arrows). Metastases are also seen in the adrenal glands (open arrows, #2), small intestine (arrow, #3) and right ventricle of the heart (arrow, #4).\n\nComment: Melanoma is occasionally recognized as a "hypervascular" tumor, with liver metastases that may be more conspicuous on hepatic arterial phase images. However, most melanoma metastatic lesions are well-depicted on CECT in the portal venous phase.', 'history': 'Patient with known melanoma.', 'imagePoolId': '41a44f45-5398-4db1-97e2-2fcf44edc9ac', 'name': 'Hypovascular', 'teachingPoint': None, 'demographics': '43 Years old male'}, {'authors': [{'key': '64470aa4-5429-4786-81fa-be44c86ca020', 'value': 'Kristine S Spinelli, MD'}], 'caseVersionId': '2dd42a3b-64dd-4924-bbf1-90377088320d', 'description': 'Typical case of large hepatic lymphoma on MR of the abdomen.\n\nA large solitary hyperintense hepatic mass in seen on T2WI with fat-saturation (arrow, #1). It decreases in signal intensity on heavily weighted T2 imaging (arrow, #2), consistent with a solid tumor. This mass is hypovascular, as reflected on early phase IV gadolinium-enhanced images (arrows, #3), and slowly fills in on delayed images (arrow, #4).', 'history': 'Patient with right upper quadrant pain.', 'imagePoolId': 'a5cde1a7-7bf8-4398-baf1-6fe86b4fa2b5', 'name': 'Large lymphoma', 'teachingPoint': None, 'demographics': '87 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'c610c3e7-8077-44e0-8646-79a02a8e1652', 'description': 'CECT (#1,2) shows multiple liver metastases. In the sigmoid colon there is an apple core lesion (arrow, #2) causing abrupt obstruction of the colon.', 'history': 'Crampy abdominal pain and weight loss.', 'imagePoolId': '257f9837-f0eb-46f0-80ed-839bde3634cc', 'name': 'With liver metastases; apple core', 'teachingPoint': None, 'demographics': '37 Years old male'}, {'authors': [{'key': '11951537-5325-4ab3-8914-c6b3eedb3ebb', 'value': 'Bhawan K. Paunipagar, MBBS, MD, DNB'}, {'key': '26828c43-b203-40f1-a5c3-02ef9d4f4675', 'value': 'Anil T. Ahuja, MD, FRCR'}], 'caseVersionId': 'bd6c8980-20ea-47d1-b8ac-b79dd9cce6e2', 'description': 'Typical case of echogenic liver metastasis.\n\nGrayscale transabdominal ultrasound of liver (#1-2) shows typically echogenic (arrows) liver metastases from colonic carcinoma.', 'history': 'Patient with known carcinoma colon, presented with hepatomegaly and raised CEA levels.', 'imagePoolId': 'acbfcac3-db8e-446b-84d9-90de580853e5', 'name': 'Echogenic', 'teachingPoint': None, 'demographics': '71 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'bc30bbce-57a0-4878-9fae-4fd0208b5a2b', 'description': 'Multiple liver metastases are seen having several typical features, including a continuous ring of enhancement on T1WI (arrows, #1) and heterogeneous hyperintensity on T1WI (arrows, #2).', 'history': 'Colon carcinoma with weight loss.\n', 'imagePoolId': '78d55ca7-9448-4e92-8549-88e4769105cc', 'name': 'Colon mets with halo on MR', 'teachingPoint': None}, {'authors': [{'key': '11951537-5325-4ab3-8914-c6b3eedb3ebb', 'value': 'Bhawan K. Paunipagar, MBBS, MD, DNB'}, {'key': '01bde7cf-c6c0-41b5-bdea-0eb9bdfd785c', 'value': ' Prince of Wales Hospital, HK'}, {'key': '26828c43-b203-40f1-a5c3-02ef9d4f4675', 'value': 'Anil T. Ahuja, MD, FRCR'}], 'caseVersionId': '38ca9adb-10d6-4a71-b19a-b96365d1eb11', 'description': 'Typical case of echogenic liver metastases.\n\nGrayscale (#1,2) and color Doppler (#3-4) ultrasound shows typical, multiple, echogenic (arrows, #1-2) liver metastases from colonic carcinoma. Note the avascularity of the liver lesions (open arrows, #3-4). \n\nComment: There is list of differential diagnoses for multiple echogenic liver lesions which includes hemangiomas, vascular metastases from primary neuroendocrine tumour, choriocarcinoma, melanoma and colonic carcinoma.', 'history': 'Patient with a known carcinoma of colon, presents with tender hepatomegaly.', 'imagePoolId': '8f41e8c5-5224-4c99-9c56-777e826d0cfd', 'name': 'Echogenic', 'teachingPoint': None, 'demographics': '68 Years old male'}, {'authors': [{'key': '11951537-5325-4ab3-8914-c6b3eedb3ebb', 'value': 'Bhawan K. Paunipagar, MBBS, MD, DNB'}, {'key': '01bde7cf-c6c0-41b5-bdea-0eb9bdfd785c', 'value': ' Prince of Wales Hospital, HK'}, {'key': '26828c43-b203-40f1-a5c3-02ef9d4f4675', 'value': 'Anil T. Ahuja, MD, FRCR'}], 'caseVersionId': 'e956a0e8-31e6-4397-a379-426042587962', 'description': 'Typical case of multiple liver metastases.\n\nGrayscale ultrasound of liver (#1-2) shows multiple discrete hypoechoic metastases (arrows). Note ascites (open arrow) in the abdomen. \n\nComment: Hypoechoic metastases are often from cervical cancer, lung cancer (adenocarcinoma), nasopharyngeal cancer, pancreatic cancer and lymphoma.', 'history': 'Patient with known carcinoma of ovary. Routine follow up sonogram.', 'imagePoolId': '42fd97f6-00c9-433f-87a4-e267f96fba67', 'name': 'Multiple', 'teachingPoint': None, 'demographics': '57 Years old female'}, {'authors': [{'key': '64470aa4-5429-4786-81fa-be44c86ca020', 'value': 'Kristine S Spinelli, MD'}], 'caseVersionId': '8cce957e-251a-445a-bdd1-204a12b4c48c', 'description': 'Typical cystic or necrotic hepatic metastases on CECT.\n\nAxial CECT images show multiple low attenuation lesions throughout the liver. Note bilateral adrenal metastases (arrows, #1). The primary tumor is seen in the pancreatic body encasing the superior mesenteric and left renal arteries (arrows, #2, 3).\n \nComment: Metastases from cystic primary tumors, such as ovarian cystadenocarcinoma, may truly appear cystic on imaging, with contents measuring near water attenuation on CT, and being hyperintense on T2WI MR. In most cases, even necrotic metastases, such as in this case, will show mural nodularity or other signs of complexity not seen with simple hepatic cysts.', 'history': 'Severe abdominal pain and weight loss.', 'imagePoolId': '64b7a446-f227-4597-8e8d-84cbe0af05de', 'name': 'Cystic/necrotic', 'teachingPoint': None, 'demographics': '57 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '8aac93d3-f5de-4cb8-8135-4ee42b9723b2', 'description': "Arterial-phase CECT images (Figs. 1-3) show innumerable hypervascular metastases (, Figs. 1-2) filling the liver. The primary tumor is in the pancreas and is also hypervascular (, Fig. 3). The metastases are much less evident on the portal venous-phase CECT (Fig. 4); some washout to become hypodense to liver, while others are nearly isodense and undetectable. This patient developed liver failure from his metastases and had resection of his pancreatic tumor and liver transplantation. Disease recurrence was evident within lymph nodes and the peritoneal cavity within 2 months of transplantation.", 'history': 'Patient presents with weight loss.', 'imagePoolId': 'df5f15e0-8eac-4e01-8501-cb9be3da01c1', 'name': 'Pancreatic Neuroendocrine Tumor With Extensive Hypervascular Liver Metastases', 'teachingPoint': 'The enhancement pattern of neuroendocrine tumor metastases (most often to the locoregional lymph nodes and liver) is similar to the primary tumor with avid hypervascularity most evident on the arterial-phase images.', 'demographics': '57 Years old male'}, {'authors': [{'key': '11951537-5325-4ab3-8914-c6b3eedb3ebb', 'value': 'Bhawan K. Paunipagar, MBBS, MD, DNB'}, {'key': '01bde7cf-c6c0-41b5-bdea-0eb9bdfd785c', 'value': ' Prince of Wales Hospital, HK'}, {'key': '26828c43-b203-40f1-a5c3-02ef9d4f4675', 'value': 'Anil T. Ahuja, MD, FRCR'}], 'caseVersionId': '7c71f16f-3ed7-4172-9436-1692fe1f3e24', 'description': 'Typical case of echogenic liver metastases.\n\nGrayscale and color Doppler ultrasound images (#1-3) show multiple, large, lobulated, homogeneously echogenic liver metastases (arrows) with mass effect on intrahepatic portal vessels (curved arrow, #3). \n\nComment: In a known case of carcinoma colon, multiple echogenic liver masses invariably represent hepatic metastasis.', 'history': 'Patient is known to have carcinoma sigmoid colon with colectomy done. On chemotherapy.', 'imagePoolId': '3cf0315f-6209-470b-87fe-6ae637b3002b', 'name': 'Echogenic', 'teachingPoint': None, 'demographics': '45 Years old male'}, {'authors': [{'key': '11951537-5325-4ab3-8914-c6b3eedb3ebb', 'value': 'Bhawan K. Paunipagar, MBBS, MD, DNB'}, {'key': '01bde7cf-c6c0-41b5-bdea-0eb9bdfd785c', 'value': ' Prince of Wales Hospital, HK'}, {'key': '26828c43-b203-40f1-a5c3-02ef9d4f4675', 'value': 'Anil T. Ahuja, MD, FRCR'}], 'caseVersionId': '43863151-b11d-46dc-9bf3-2379da219cba', 'description': 'Typical case of hepatic metastases.\n\nGrayscale ultrasound images of liver (#1-4) show multiple ill-defined hypoechoic masses (arrows) in both liver lobes. Color and power Doppler ultrasound showed no specific vascular pattern (images not shown). Preliminary diagnosis of hepatic metastases was suggested. A CECT revealed primary carcinoma of the splenic flexure of colon, with hepatic masses.', 'history': 'Incidental finding. Patient presented with deranged liver functions. Occasional bowel discomfort.', 'imagePoolId': '916b9eec-505c-4abe-8059-be81cce739ad', 'name': 'Ill-defined', 'teachingPoint': None, 'demographics': '61 Years old female'}, {'authors': [{'key': '11951537-5325-4ab3-8914-c6b3eedb3ebb', 'value': 'Bhawan K. Paunipagar, MBBS, MD, DNB'}, {'key': '01bde7cf-c6c0-41b5-bdea-0eb9bdfd785c', 'value': ' Prince of Wales Hospital, HK'}, {'key': '26828c43-b203-40f1-a5c3-02ef9d4f4675', 'value': 'Anil T. Ahuja, MD, FRCR'}], 'caseVersionId': 'dc4b6922-6367-4032-836f-e672edb0fef3', 'description': 'Typical case of hepatic metastases from pancreatic adenocarcinoma.\n\nGrayscale (#1-3) and power Doppler (#4) ultrasound images show multiple mixed echogenic metastases (arrows, #1-2) in liver. There is an inconspicuous mass at the pancreatic head (open arrow, #3-4), causing obstruction of the pancreatic duct (curved arrows, #3) which is dilated. Power Doppler ultrasound (#4) demonstrates distinct vascularity of pancreatic head malignancy.', 'history': 'Patient was diagnosed to have pancreatic adenocarcinoma. Now presented with clinical features suggestive of of obstructive jaundice.', 'imagePoolId': '7c31ee31-7837-488a-bc51-6b7488897314', 'name': 'Mixed', 'teachingPoint': None, 'demographics': '63 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '47c953df-4a49-46b3-a593-5fc6e258f2a4', 'description': 'CT shows metastases to the liver (black arrow, #1) and small bowel (white arrow, #2) with the latter leading to intussusception which was the cause of the acute pain.', 'history': 'Known melanoma, with acute, crampy, abdominal pain.', 'imagePoolId': 'ff85e0b3-d628-4bfb-84a4-66be5c3dab2e', 'name': 'With small bowel intussusception due to mets', 'teachingPoint': None, 'demographics': '58 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '4899293f-1a1e-4675-91cb-64fd32a408d2', 'description': "Axial CECT images (Figs. 1-5) show all the classic findings of pancreatic head ductal adenocarcinoma, with a small hypodense mass in the head (, Fig. 5) that causes obstruction and dilation of the pancreatic duct (, Fig. 2) and bile ducts (, Fig. 1), with a very dilated gallbladder (, Figs. 1-2, 4). Also evident are metastases to the liver (, Fig. 3) and lymph nodes (, Fig. 3).", 'history': 'Patient presents with painless jaundice.', 'imagePoolId': '1a9525de-297a-44e8-9fbd-de953eb7f3df', 'name': 'Pancreatic Ductal Adenocarcinoma (Classic) With Dilated Ducts, Lymph Nodes, and Liver Metastases', 'teachingPoint': 'Pancreatic adenocarcinoma classically results in pancreatic and biliary ductal obstruction (when located in the pancreatic head), and most commonly metastasizes to the liver and peritoneum.', 'demographics': '56 Years old male'}], 'caseType': 'typical', 'name': 'TYPICAL'}
+- {'cases': [{'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '0ba0d867-c137-413d-9155-c7231dbedb39', 'description': 'MR shows multiple metastases (arrows, #1,2) that have the peculiar feature of being hyperintense on T1WI (#1), which is attributed to the melanin in these lesions. Most metastases are hypo- or isointense to liver on T1WI.', 'history': 'Malignant melanoma with suspected liver metastases.', 'imagePoolId': 'edb886bb-8613-4c97-9382-041a1316848b', 'name': 'Melanoma mets to the liver; hyper on T1WI', 'teachingPoint': None, 'demographics': '70 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '42aeefcf-cd76-4129-a976-e72419013f25', 'description': "Axial CECT images (Figs. 1-3) show a large, complex cystic pancreatic mass with mural nodularity (, Figs. 1-2), suggestive of invasive malignancy, with more definitive evidence of malignancy in the form of liver (, Fig. 1) and peritoneal (, Figs. 2-3) metastases, along with malignant ascites (, Fig. 2).", 'history': 'Abdominal discomfort and weight loss.', 'imagePoolId': 'f13a07b2-4234-4db0-8058-a10e57ea4637', 'name': 'Mucinous Cystic Neoplasm With Invasive Malignancy and Liver Metastases', 'teachingPoint': 'Invasive malignancy arising from a mucinous cystic neoplasm or intraductal papillary mucinous neoplasm often have a similar pattern of spread to pancreatic ductal adenocarcinoma, with metastases to the liver and peritoneum most common.', 'demographics': '75 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'f6518a9d-4b22-4fef-9823-62478d7a33c6', 'description': 'CECT (#1,2) shows what appears to be a simple cyst in the liver (arrow, #1). However, other sections showed shaggy walls to hepatic and extrahepatic masses (open arrows, #2), typical of metastatic sarcoma.', 'history': 'Known sarcoma; evaluate for metastases.', 'imagePoolId': '597c6d00-7198-431b-b597-1025e5bde60b', 'name': 'Cystic mets; sarcoma primary', 'teachingPoint': None}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '81715967-3761-4e8e-af50-0ec498e9b807', 'description': 'CT (#1-3) shows multiple cystic-appearing liver lesions,(arrows, #1,2). While these could represent simple cysts or biliary hamartomas, their number, variable size, and irregular borders favor metastases. The left ureter was obstructed by the recurrent pelvic tumor (not shown) resulting in hydronephrosis (curved arrow, #3) with a ureteral stent in place.', 'history': 'Woman with prior resection of an ovarian cancer, now with flank pain and weight loss.', 'imagePoolId': '653fe01a-f535-4c88-991b-46cd3a5b140b', 'name': 'Cystic mets; ovarian cancer', 'teachingPoint': None, 'demographics': '57 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '86d8eea9-d2ca-4a0d-b90d-26a10d350f3f', 'description': 'CECT (#1-4) shows multifocal hypodense masses (arrows) in the liver, spleen, kidney, and abdominal nodes.', 'history': 'Young man with AIDS and weight loss.', 'imagePoolId': '28492ef2-454d-4473-ab26-de910ef9598d', 'name': 'AIDS with NHL; abdominal organs & nodes', 'teachingPoint': None, 'demographics': '34 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '87608433-cffc-41c9-9183-9764a7809111', 'description': 'CT (#1-4) shows multiple cystic-appearing liver masses. Only the subtle nodularity in the "cyst" walls (arrows) indicate that these are not simple cysts, but proved to be metastases. Also noted is metastasis to the right adrenal gland (curved arrow, #2).', 'history': 'Thyroid cancer for follow-up.', 'imagePoolId': 'e0fad43c-1a9e-47a7-afb1-0e2b9c4edef9', 'name': 'Cystic liver mets from thyroid cancer', 'teachingPoint': None}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '3f99644f-02f5-4197-b72c-1bc5bb12478e', 'description': 'Axial arterial phase CECT images (#1-2) show heterogeneous hypervascular foci (arrows) in the left and caudate lobes of the liver. Axial venous phase CECT images (#3-6) show mixed hypo- and hyperdense lesions in the same distribution, with a straight line demarcation from normal liver (curved arrows) corresponding the the radiation therapy port.\n\nComment: Radiation hepatitis (radiation-induced liver disease) usually results in a geographic zone of low attenuation within the portion of the liver included in the port. Acute injury can result in mixed hypervascular and veno-occlusive hepatic injury, as seen in this case. It is important to distinguish this from metastatic esophageal carcinoma, which would not result in hypervascular lesions or the straight line demarcation seen in this case.', 'history': 'Follow-up 1 month after external beam radiation therapy for esophageal carcinoma with liver metastasis.', 'imagePoolId': 'ffce37cf-f9ff-4302-8213-ac1164bdcda2', 'name': 'Following treatment for liver metastasis', 'teachingPoint': None, 'demographics': '65 Years old male'}, {'authors': [{'key': '11951537-5325-4ab3-8914-c6b3eedb3ebb', 'value': 'Bhawan K. Paunipagar, MBBS, MD, DNB'}, {'key': '01bde7cf-c6c0-41b5-bdea-0eb9bdfd785c', 'value': ' Prince of Wales Hospital, HK'}, {'key': '26828c43-b203-40f1-a5c3-02ef9d4f4675', 'value': 'Anil T. Ahuja, MD, FRCR'}], 'caseVersionId': '8c9b97f6-6d89-4e61-ac81-966f8c3812c5', 'description': 'Typical case of cystic liver metastasis.\n\nGrayscale (#1-5) and color Doppler (#6) ultrasound images show multiple cystic metastases (arrows) in right lobe of liver, with thick echogenic walls (curved arrow, #1-5). Color Doppler demonstrates peripheral vascularity (white open arrow, #6). The adjoining vessels appear displaced (black open arrow, #6)', 'history': 'Patient with known nasopharyngeal carcinoma, under treatment. Deranged LFTs.', 'imagePoolId': 'bd160962-1341-4bc3-b66a-8b78bfd4cb2f', 'name': 'Cystic', 'teachingPoint': None, 'demographics': '48 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '4d5dac06-4a01-4b50-8982-106a3d1033e4', 'description': 'Ultrasound shows an echogenic mass (open arrow, #1) near the confluence of hepatic veins. CT shows the same mass (arrows, #2,3) having the typical appearance of a metastasis, rather than a hemangioma.', 'history': 'Neuroendocrine tumor.', 'imagePoolId': '3f8858c0-d790-4d95-8f46-ed2f3ff47323', 'name': 'Echogenic met; simulates hemangioma', 'teachingPoint': None, 'demographics': '60 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '7351b89d-87cd-49bc-8c48-f6cd0613504c', 'description': "A series of axial (#1-4) and coronal reformatted (#5-6) CECT sections shows numerous focal, spherical, heterogeneous, hypodense masses within the liver and spleen (white arrows, #1-6) and similar lesions within the kidneys (black arrows, #3-6), all representing metastatic foci from this patient's lung cancer. Also seen are heterogeneous mixed lytic and sclerotic vertebral lesions, associated with partial collapse, that are also due to metastases (open arrows, #5-6). A smaller lesion with continuous rim enhancement is also seen in the paravertebral muscle (curved arrow, #1), also likely representing a metastasis.\n\nComment: While lung cancer is not regarded as a tumor unique to immunocompromised patients, such patients, including those with AIDS, often have a peculiarly aggressive form of whatever malignancy or infection they may encounter.", 'history': 'Recent weight loss and back pain in a man with AIDS.', 'imagePoolId': '2d064dcc-3f51-4314-8bb4-05ad89fd3c06', 'name': 'Multisystem from lung cancer in patient with AIDS', 'teachingPoint': None, 'demographics': '56 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '3ab4fcdf-1a06-4e5b-afeb-c5b3403ecdf8', 'description': 'CT shows metastasis to the liver (arrow, #1) that is peculiarly heterogeneous and high density, perhaps indicating bleeding within the metastasis. Immediately adjacent to this metastasis is a heterogeneous "sentinel clot" (curved arrow, #2) strongly suggesting bleeding from the mets. Also noted is extensive hemoperitoneum (open arrows, #1-3), having an attenuation of 35 HU.', 'history': 'Melanoma with acute abdominal pain and falling hematocrit.', 'imagePoolId': '06ca5cdf-a868-4f63-ad78-439f16a9a276', 'name': 'Mets to liver with hemoperitoneum', 'teachingPoint': None, 'demographics': '55 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '8de85f0e-9a9f-4603-90b0-6270ff69e332', 'description': 'Axial and coronal CECT (#1-7) show multiple liver metastases (curved arrows, #1, 4) and malignant ascites (open arrows, #1, 4) with large omental metastatic masses (black arrows, #2-7). An unexplained finding was the presence of a brightly enhancing mesenteric mass (white arrows, #3-9) that enhances to the same degree as the spleen. The volume rendered CT reformations (#8-9) were helpful in identifying the vascular branches of the gastroepiploic vessels (curved arrows) that supplied the mesenteric mass, which proved to be an accessory spleen.', 'history': 'Follow-up metastatic ovarian carcinoma.', 'imagePoolId': '89323ec4-0546-4fa2-a93d-f15708c20461', 'name': 'In mesentery', 'teachingPoint': None, 'demographics': '47 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '8ff68833-b08d-4a5e-9841-11d7d93b134b', 'description': 'NECT shows multiple liver metastases, some of which have scattered or heavy calcification (arrows).', 'history': 'Colon carcinoma.', 'imagePoolId': '8755f6f5-a433-4f0d-bb8a-1de2f1f66a76', 'name': 'Heavy calcification; colon mets', 'teachingPoint': None, 'demographics': '50 Years old male'}, {'authors': [{'key': '11951537-5325-4ab3-8914-c6b3eedb3ebb', 'value': 'Bhawan K. Paunipagar, MBBS, MD, DNB'}, {'key': '01bde7cf-c6c0-41b5-bdea-0eb9bdfd785c', 'value': ' Prince of Wales Hospital, HK'}, {'key': '26828c43-b203-40f1-a5c3-02ef9d4f4675', 'value': 'Anil T. Ahuja, MD, FRCR'}], 'caseVersionId': '955c7e22-9984-4b4c-90fe-e3499de4911b', 'description': 'Atypical case of hepatic metastases.\n\nGrayscale ultrasound of liver (#1-3) shows echogenic, calcified metastases (arrows) with poor posterior shadowing (open arrow, #1). These are difficult to be differentiated from calcified granulomas. The history of primary tumor elsewhere substantiates the diagnosis of metastasis.\n\nComment: Cancers with calcified metastases include tumors from breast, renal cell carcinoma, medullary thyroid carcinoma, mucinous carcinoma from GI tract, melanoma etc.', 'history': 'Patient known to have primary neoplasm, undergoing chemotherapy.', 'imagePoolId': 'd6b0cd5f-7d21-43a5-9e4b-439764b13dbf', 'name': 'Calcified', 'teachingPoint': None, 'demographics': '63 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '9cfb4662-2562-4748-bc2d-9b92e72d2fa5', 'description': 'Axial CECT sections (#1-12) show widespread metastases (arrows, #1,3,5,7,9) throughout the liver and spleen. Gas is present within the lumen and wall of the gallbladder (open arrows, #7,9), and the gallbladder wall appears to be perforated (curved arrow, #8). Ascites is also present. \n\nComment: Gangrenous perforation of the gallbladder was confirmed at surgery, possibly related to the chemotherapy that the patient was receiving.', 'history': 'Abdominal pain, fever, and a history of melanoma being treated with chemotherapy.', 'imagePoolId': 'a9a59cd1-28e2-460b-aaba-fbb8f7657ce0', 'name': 'With melanoma in liver and spleen', 'teachingPoint': None, 'demographics': '75 Years old female'}, {'authors': [{'key': '64470aa4-5429-4786-81fa-be44c86ca020', 'value': 'Kristine S Spinelli, MD'}], 'caseVersionId': 'a7903c8a-1d49-4c30-a445-28689e490c89', 'description': 'Variant case of calcified hepatic metastases on NECT and CECT from colon cancer.\n\nPre-contrast CT (#1, 3) shows multiple lesions with faint central calcification (arrows). CECT (#2, 4) at the same levels shows peripheral enhancement and central necrosis. Note how the calcifications are much harder to see after contrast administration.', 'history': '4 cm ulcerated rectal cancer.', 'imagePoolId': '544de429-217d-41ac-b72f-ec2440114524', 'name': 'Calcified', 'teachingPoint': None, 'demographics': '43 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'a9ab9d79-eec3-4095-9614-8dde87b176a9', 'description': 'Axial CECT shows diffuse low attenuation throughout the liver, suggestive of steatosis. In addition, there are several poorly defined hypodense lesions (arrows, #1,3-4) that might represent focal steatosis or metastases. Sonography the next day confirmed innumerable focal hypoechoic metastases (arrows, #5-8) and no evidence of the diffuse increased echogenicity that would be expected for steatosis. This represents diffuse hepatic melanoma metastases.\n\nComment: In a patient with known malignancy (especially breast cancer, melanoma, and lymphoma), caution is needed before attributing diffuse hepatic hypoattenuation to simple steatosis, as widespread malignant infiltration may have a similar appearance. In such cases, sonography may confirm discrete focal lesions that might be amenable to biopsy. PET-CT is also of value, as most malignant hepatic lesions are FDG avid, while steatosis is not.', 'history': 'Patient with known melanoma and new progression of liver dysfunction.', 'imagePoolId': 'd8bf4db3-4738-4f02-8d21-fb6a4a5af2c0', 'name': 'Diffuse, simulating steatosis, better shown on US', 'teachingPoint': None, 'demographics': '60 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'b16553a6-ac2e-4d6c-bc78-d64ca6318968', 'description': 'Arterial phase CECT (#1) shows a large peripheral wedge-shaped THAD (arrow) that disappears on portal venous phase images (#2). Several liver metastases (curved arrows, #2-3) were noted, although the metastasis that is the presumed cause of the THAD was not identified with confidence. The pancreatic body carcinoma is noted (open arrow, #3).', 'history': 'Pancreatic cancer.', 'imagePoolId': 'bb34f12b-c401-4afc-9de8-eb60796f9e40', 'name': 'From metastatic pancreatic cancer', 'teachingPoint': None, 'demographics': '70 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'b9e21c0c-e584-4ef4-8879-ef3fc7dad63d', 'description': 'A biphasic contrast-enhanced CT scan was performed. Axial sections obtained in the arterial phase of imaging (#1-3) show peripheral, wedge-shaped zones of hepatic hyperperfusion (arrows) that become isodense to liver on the portal venous phase of imaging (#4-8). The latter phase more optimally demonstrates the multiple hypodense, spherical metastases (curved arrows, #4-7), some of which accounted for the transient hepatic attenuation differences (THAD) lesions seen on arterial phase images.\n\nComment: THAD lesions often result from occlusion of portal vein branches, resulting in delivery of undiluted contrast medium during the arterial phase to segments of liver with diminished or absent portal flow. Metastases from GI tract malignancies are a common source or portal vein/hepatic metastases.', 'history': 'Known pancreatic cancer; evaluate for metastases.', 'imagePoolId': 'e0d2f41b-5836-4b88-b672-436dc147c683', 'name': 'Due to metastases from pancreatic cancer', 'teachingPoint': None, 'demographics': '55 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '34328390-a5ef-4e21-85c1-81a7b3f3e6a9', 'description': 'The initial CT scan (#1,2) shows a hypodense but solid mass (arrows) that represents viable metastasis. Following treatment, the mass (arrow, #3) is smaller and appears cystic. \n\nComment: Without the proper history, this might be mistaken for a benign cyst.', 'history': 'Metastatic GIST, being treated with imatinib.', 'imagePoolId': 'e814a5cf-0406-4776-aec1-60ea00908ff1', 'name': 'Metastatic GIST;cystic in response to Gleevec imatinib', 'teachingPoint': None, 'demographics': '74 Years old male'}, {'authors': [{'key': 'c3463c5c-31d3-4489-bbfe-6b895abdb86d', 'value': 'Mitchell Tublin, MD'}], 'caseVersionId': '33dbdcef-5b79-406a-ba80-c3a1e5c6c199', 'description': 'A series of ultrasound images (#1-4) show marked coarsening of hepatic echotexture. Note compression of the middle hepatic vein (arrows, #1), anterior segment hypoechogenicity (curved arrows, #2), and scant perihepatic ascites (open arrow, #4). Contrast-enhanced CT (#5-7) shows hepatomegaly and innumerable poorly defined, coalescent, perivascular and perihepatic low-attenuation metastases. Note compression of the right hepatic vein (arrows, #5,6) and retrohepatic inferior vena cava (curved black arrow, #6).\r\n\r\nPearl: Infiltrating hepatic metastases may often be mistaken for cirrhosis (as was the case initially for this unfortunate patient). A diligent search for more confluent regions of abnormal echogenicity and refractive shadows (due to interfaces between tumor and unaffected liver) may result in a correct diagnosis, but contrast-enhanced MR or CT is often necessary. An ultrasound-guided liver biopsy performed on this patient prior to initiating palliative chemotherapy confirmed extensive infiltrating breast carcinoma.', 'history': 'Patient with history of stage 3A ductal breast carcinoma, status post neoadjuvant chemotherapy and mastectomy 2 months prior; admitted with right upper quadrant pain, elevated liver function tests, and jaundice.', 'imagePoolId': '40d020aa-9305-4cad-a09a-296ab0cf2fe7', 'name': 'Infiltrating tumor, mimics cirrhosis', 'teachingPoint': None, 'demographics': '61 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'c2d19752-4249-4d3a-b569-0f217c1a6410', 'description': 'A series of arterial phase CECT sections shows numerous small hepatic masses (black arrows, #1-5), some of which are uniformly hyperenhancing, while others enhance heterogeneously or with ring enhancement. Venous phase images (#6-9) show many fewer lesions (black arrows, #6-7). There is a large heterogeneous soft tissue density mass (white arrows, #8-9) arising from the jejunum (curved arrow, #8). Resection of the jejunal mass proved to be a GI stromal tumor, and liver metastases were also documented.\n\nA repeat CECT was obtained 4 weeks later (#10-12), following chemotherapy that included a tyrosine kinase inhibitor (imatinib). Many of the liver metastases disappeared completely (also on arterial phase images, not shown), while other lesions became so completely necrotic as to simulate simple hepatic cysts or thrombosed hemangiomas (curved black arrows, #10-12).\n\nComment: The small intestine beyond the duodenum is an unusual site for a GIST. The hypervascular, heterogeneous metastases are typical of lesions from a hypervascular primary tumor, such as GIST, and may be evident only on arterial phase imaging. Chemotherapy, particularly imatinib, may result in such complete necrosis of metastases as to render these similar to hepatic cysts. Comparison to pretherapy images is obviously important.', 'history': 'Crampy abdominal pain and blood in stool.', 'imagePoolId': '4ba77100-5f00-407d-b53d-292de7ad2387', 'name': 'Primary in small bowel, cystic metastases', 'teachingPoint': None, 'demographics': '30 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '324dc9ac-211d-4e0c-9c3a-73c536600d22', 'description': 'Axial CECT images (#1-6) show several near-water-density hepatic lesions (arrows, #1-3, 5) that may be compared with the appearance of a simple renal cyst (curved arrows, #2-3) or the gallbladder (curved arrow, #6). Indications that the hepatic lesions are not simple cysts include the subtle wall thickening and irregularity and the obstruction of intrahepatic bile ducts (open arrows, #4-5).\n\nComment: Cystic (or necrotic) hepatic metastases may occur with almost any primary cancer, but are especially likely to result from metastatic sarcomas (including GIST) and squamous cell carcinomas.', 'history': 'Squamous cell carcinoma of the tongue, for staging.', 'imagePoolId': 'b5c80a4d-924b-49c6-aa32-a30a079ba0cb', 'name': 'Cystic liver mets, tongue, SCC', 'teachingPoint': None, 'demographics': '42 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '2262f3b9-2bf7-43da-8d60-0941bd00a078', 'description': 'A series of axial (#1-4) and coronal reformatted (#5-8) CECT sections shows poorly defined low density (arrows, #1-8) replacing most of the right lobe of the liver, with patchy low density foci in the left lobe as well. Hepatic blood vessels (curved arrows, #1-4,6-8) are surrounded but show no obvious obstruction. Also noted are ascites (black arrow, #3) and upper abdominal lymphadenopathy (open arrows, #2-4,6-8).\n\nOne week later, a PET-CT scan was performed. Axial NECT images (#9-10) show that the abnormal portions of the liver (arrows, #9-10) are hyperdense to underlying normal liver and are FDG-avid on the PET portion of the exam (arrows, #11-13). The enlarged upper abdominal nodes are also FDG-avid (open arrow, #13).\n\nComment: Some forms of hepatic metastases (especially from breast cancer and melanoma) and lymphoma may infiltrate the liver so diffusely as to simulate hepatic steatosis (fatty liver). In this case, the presence of ascites and lymphadenopathy, along with the density of the hepatic lesion relative to liver on the NECT, suggested the presence of metastasis. Percutaneous liver biopsy or PET evaluation may be necessary in some cases.', 'history': 'Patient with known invasive breast cancer; CT requested to evaluate for metastases.', 'imagePoolId': '84dd0295-7d1d-4b75-b4bc-844de3b4fd7f', 'name': 'Breast metastases simulating fatty liver', 'teachingPoint': None, 'demographics': '59 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'cb2bf55f-bed3-45f3-b5a5-60e82be5c595', 'description': 'A standard series of T2WI (#1-3) and T1WI MR (not shown) demonstrated 4 metastatic deposits (arrows) within the liver. A series of T1WI MR images obtained 20 minutes after the IV administration of gadoxetate (Eovist), a hepatobiliary contrast medium, (#4-7) revealed at least 3 additional metastases (curved arrows, # 4,6).\n\nComment: Patients who have 6 or more hepatic metastases are usually considered to be candidates for systemic cancer therapy rather than regional treatment, such as radiofrequency ablation or partial hepatectomy. Gadoxetate results in intense enhancement of normal hepatic parenchyma and can make small metastases much more evident than on routine MR or CT evaluation.', 'history': 'Colon cancer with liver metastases; considering resection or ablation.', 'imagePoolId': 'b9370efc-acf3-4545-a05f-c3c355095e9a', 'name': 'On gadoxetate-enhanced MR', 'teachingPoint': None, 'demographics': '44 Years old male'}, {'authors': [{'key': '64470aa4-5429-4786-81fa-be44c86ca020', 'value': 'Kristine S Spinelli, MD'}], 'caseVersionId': '1f67a92d-d335-46a4-8ac6-9394e99b6b91', 'description': 'Variant hypervascular hepatic metastases on CECT. CT, nuclear medicine scan; metastatic neuroendocrine tumor.\n\nOn the late arterial phase images (#1, 2), large hypervascular liver lesions are seen (arrows), which are fed by the hepatic artery. Note central necrosis in the largest lesion (open arrow, #1). The lesions are less conspicuous on portal venous phase (arrows, #3) at the same level as in #2.\n\nIntense uptake is seen on the Octreotide scan (arrows, #4), consistent with a neuroendocrine tumor, which was proven with biopsy.\n\nComment: Hypervascular liver metastases usually arise from primary "endocrine" malignancies, such as neuroendocrine (carcinoid and pancreatic islet cell), and thyroid carcinomas.', 'history': '2 year history of abdominal bloating, indigestion and right subcostal pain.', 'imagePoolId': '9e052ae6-4694-4547-9faf-28d6a15cb18f', 'name': 'Hypervascular', 'teachingPoint': None, 'demographics': '52 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'd5c8168e-1369-4422-a4ea-2df827c6bb4b', 'description': 'CT (#1,2) shows several solid-appearing liver metastases (black arrows) and 2 masses with gas and necrotic debris (white arrows) that are the lesions that received RF ablation. \n\nComment: The sudden death of tissue releases gas, and does not necessarily imply infection, though imaging and clinical signs are very similar for both entities.', 'history': 'Patient with liver metastases from neuroendocrine tumor; status post RF ablation of 2 lesions.', 'imagePoolId': '8b5fc859-d3c0-4d7b-9f4f-218822966f05', 'name': 'Ablated mets with gas simulating abscess', 'teachingPoint': None, 'demographics': '35 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'dac2bcca-72b8-4006-b565-17ae31ca7acc', 'description': 'MRCP (#1) shows massive dilation of the intrahepatic ducts (curved arrow) with abrupt cutoff. MR (#2) shows multiple liver metastases (arrows), some of which have resulted in biliary obstruction (curved arrow).', 'history': 'Jaundice, history of thyroid cancer.', 'imagePoolId': '07b6e882-9f99-4371-8032-09b7916f99e3', 'name': 'Common bile duct obstruction; thyroid met', 'teachingPoint': None, 'demographics': '49 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '1cce17fc-e07b-4cbc-8cb1-191bb1a04082', 'description': 'CECT (#1-5) shows numerous hepatic metastases (arrows), some of which have been treated with RF ablation. One of these has gas within it (curved arrows) as well as surgical clips, the latter the result of bleeding after ablation that required intervention. \n\nComment: The gas bubbles are not the result of infection but rather infarction of hepatic tissue (or tumor) whose sudden death released cellular gas in this form.', 'history': 'Colorectal carcinoma with liver metastases; status post radiofrequency (RF) ablation.', 'imagePoolId': '8d4671a7-ca36-44e1-8a0c-38ef5db8beb8', 'name': 'Liver metastases following RF ablation; one with gas', 'teachingPoint': None, 'demographics': '73 Years old male'}, {'authors': [{'key': '074adeb1-51f1-486e-a476-d495527dca11', 'value': 'Gregory E. Antonio, MD, DRANZCR, FHKCR'}], 'caseVersionId': 'fde1ed3e-887d-4ced-9f58-2da28b920557', 'description': 'Solitary hepatic metastasis showing irregular borders.\n\nGrayscale (#1-3) and color Doppler (#4) ultrasound of the liver shows a solitary mass (arrows) with lobulated/irregular borders. The lesion is hypoechoic and has a heterogeneous echotexture, both features are non-specific. There is some peripheral vascularity on Color Doppler (#4).\n\nComment: Solitary hepatic lesions are often non-specific on imaging. Correlation with the clinical history is important. In a patient with a known carcinoma the lesion should be considered metastatic until proven otherwise. A biopsy is often indicated to confirm the nature of the mass.', 'history': 'Patient has a history of lung carcinoma. Presented with hepatomegaly and abnormal liver function tests.', 'imagePoolId': '7a30b37d-1675-4f40-b121-0d3ac02bfcba', 'name': 'Irregular borders', 'teachingPoint': None, 'demographics': '59 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '19bff6e4-411b-492b-8f34-e709f134a56d', 'description': 'CT shows a large liver metastasis. The presence of calcification limited to the rim is well seen on NECT (arrow, #1) and often results from deposition of calcium at the border of viable and necrotic tumor. CECT (#2) shows no enhancement of the metastasis; the calcification is less evident on CECT.', 'history': 'Colon carcinoma, receiving chemotherapy.', 'imagePoolId': '1af4c9f8-0d78-453d-8917-12290a0e35a6', 'name': 'With peripheral calcification; treated colon met', 'teachingPoint': None, 'demographics': '57 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'ff03bf21-d7eb-4592-b04e-0ae884b2bda9', 'description': 'NECT (#1) shows an enlarged low attenuation liver that might be misinterpreted as steatosis. CECT (#2-4) shows innumerable hypervascular liver metastases (arrows). Ascites is also present.', 'history': 'Breast cancer with right upper quadrant pain.', 'imagePoolId': 'aeb34044-4314-4012-9dbf-0619815c0dda', 'name': 'Diffuse, simulating steatosis on NECT; breast', 'teachingPoint': None}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'e3949c8b-b652-486a-8927-82621a1201d5', 'description': 'A series of axial CT sections from the initial CT scan (#1-5) demonstrates a small hypervascular mass (curved arrows, #4-5) in the head of the pancreas. There was no involvement of the pancreatic or bile ducts. A subtle, heterogeneously hypervascular focus (arrow, #1) is seen in the liver. The coronal reformations from tis study also demonstrate the small pancreatic mass (curved arrows, #6-7).\n\nAt surgery, a malignant insulinoma was resected from the pancreas, and the liver metastasis was ablated with a radiofrequency transducer.\n\nA follow-up CT scan 4 years later (#8-13) demonstrates multiple hypervascular metastases within the liver, best seen on the arterial phase images (arrows, #8-11). An interesting finding is the presence of a low-density "halo" around the metastases, best seen on the portal venous phase images (#12-13). This represents focal fatty infiltration due to the insulin-secreting liver metastases.', 'history': 'Patient with episodes of fainting due to hypoglycemia.', 'imagePoolId': 'd4b1f27e-c01f-46bf-b69f-3233b5f16fbe', 'name': 'Islet cell with focal fat around metastases', 'teachingPoint': None, 'demographics': '34 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': 'e758ef45-aa74-4332-8fb4-7eaedb3bb524', 'description': 'Arterial phase CECT (#1) shows several wedge-shaped foci of hypervascularity (arrows) that disappear on the portal venous phase image (#2). The venous phase image shows several hepatic metastases (curved arrows, #2), some of which occluded the portal vein branches by which they traveled into the liver. \n\nComment: Occlusion of the portal vein branches causes compensatory increased arterial flow to the affected segments and is visualized as THADs on arterial phases CECT.', 'history': 'Pancreatic carcinoma.', 'imagePoolId': '4646829b-bb33-49df-b191-bc44b3c3da1d', 'name': 'Due to hepatic metastases from pancreatic cancer', 'teachingPoint': None, 'demographics': '56 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '19b62fe6-a2d2-4125-9899-e220cc320ef9', 'description': 'CECT images (#1-3) show a dysmorphic liver with a lobulated and nodular contour (white arrows) that closely simulates cirrhosis. However, the presence of subtle hypodense lesions (black arrows) within the liver indicates widespread metastases. \n\nComment: In response to chemotherapy, some of the mets have shrunk in size and become fibrotic, resulting in this "pseudocirrhosis" appearance.', 'history': 'Breast cancer; on chemotherapy.', 'imagePoolId': 'e7984b3b-ec51-42e8-93eb-8365262fbb83', 'name': 'Pseudocirrhosis; treated breast mets', 'teachingPoint': None, 'demographics': '65 Years old female'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '50d7181b-6aed-433f-b666-63b4582207d6', 'description': 'NECT shows subtle hypodense metastases (black arrows) and others that are hyperdense (white arrow).', 'history': 'Malignant melanoma.', 'imagePoolId': '7310352a-d3a2-4f87-aa59-93471228dec3', 'name': 'Melanoma mets, hyperdense on NECT.', 'teachingPoint': None}, {'authors': [{'key': '250be735-0c41-4e1c-a644-065473c58aaa', 'value': 'R. Brooke Jeffrey, MD'}], 'caseVersionId': '4d80bdb6-ff53-491b-a833-fc52e81c41c9', 'description': 'Axial CECTs show an absent left kidney and bulky hypervascular masses within the pancreas (arrows, #1-2) and liver (curved arrows, #1-2). In image #1, there are peri-pancreatic varices (open arrow) from an occluded splenic vein. This case mimics a neuroendocrine tumor as a bulky hypervascular pancreatic mass with hypervascular liver metastases. The history of the nephrectomy was a key observation in suggesting the correct diagnosis.', 'history': 'Patient presented with abdominal pain 8 years after nephrectomy for renal cancer.', 'imagePoolId': 'fdde54d9-d21a-4a6e-94fe-5b9e50532b66', 'name': 'From renal cell carcinoma', 'teachingPoint': None, 'demographics': '72 Years old male'}, {'authors': [{'key': '3d84d682-9451-4b02-99b2-e34970a5b440', 'value': 'Michael P. Federle, MD, FACR'}], 'caseVersionId': '70c5453c-465a-4d50-a04c-5ef4fdb69148', 'description': 'NECT (#1) shows a large and diffusely low attenuation liver that might be misinterpreted as being due to steatosis. CECT (#2) clearly demonstrates innumerable focal lesions in the liver and spleen. Liver biopsy confirmed no-Hodgkin lymphoma.', 'history': 'Right upper quadrant pain and weight loss.', 'imagePoolId': '3aca7df1-af2a-4cbc-87a2-a20f77d95a9e', 'name': 'Diffuse lymphoma in liver (& spleen)', 'teachingPoint': None, 'demographics': '47 Years old male'}], 'caseType': 'variant', 'name': 'VARIANT'}
+
+
+## Images
+
+
+### Selected Images
+
+
+*Axial CECT shows multiple spherical liver lesions with a target appearance. This is the most typical appearance for liver metastases, especially from colon cancer. Also note the focally dilated bile ducts due to compression by the metastases.*
+
+
+*Color Doppler ultrasound in the same patient shows multiple spherical liver lesions with a target appearance , some containing visible blood vessels . This is the typical appearance of metastatic colorectal carcinoma.*
+
+
+*Axial T1WI C+ MR in a patient with metastatic colon cancer shows multiple liver metastases with several typical features, including a continuous ring of enhancement .*
+
+
+*Axial T2WI FS MR in the same patient shows heterogeneous hyperintensity within the hepatic metastases . Most metastases are heterogeneously hyperintense on T2WI and hypovascular and hypointense on T1WI.*
+
+
+*Ultrasound in a 60-year-old woman with a pancreatic endocrine tumor shows an echogenic mass near the confluence of hepatic veins that mimics the appearance of a hemangioma.*
+
+
+*Axial venous-phase CECT shows the same mass having the typical appearance of a metastasis rather than a hemangioma. In an oncology patient, sonography is generally less reliable than CT or MR in detection and characterization of solid masses, though exceptions do occur.*
+
+
+*Axial arterial-phase CECT in a patient with a metastatic carcinoid tumor shows a hypervascular metastasis adjacent to the IVC.*
+
+
+*Axial portal venous-phase CECT in the same patient shows the mass as nearly isodense to the liver and difficult to recognize. For hypervascular tumors, it is critical to obtain both arterial- and venous-phase images through the liver. Hypervascular tumors include primary HCC and adenomas, metastatic endocrine, renal, thyroid, some melanoma sarcoma, and breast cancers.*
+
+
+*Axial CECT in a patient with a metastatic GI stromal tumor (GIST) shows a heterogeneous soft tissue density metastasis .*
+
+
+*Axial CECT in the same patient following treatment shows the metastasis as a near-water-density cystic mass , which could be mistaken for a simple cyst. Cystic metastases can result from a variety of primary tumors, especially sarcomas and cystadenocarcinomas of the ovary. Attention to details, such as mural nodularity and comparison with prior imaging studies, is key.*
+
+
+*Axial T1WI FS MR in this 67-year-old woman with metastatic melanoma shows a subtle T1-hyperintense lesion . Melanoma metastases can be T1 hyperintense due to their melanin content.*
+
+
+*Axial portal venous-phase postcontrast subtraction MR shows a rim-enhancing lesion that had interval growth on the subsequent MR.*
+
+
+*Axial NECT in a patient with calcified metastases from colorectal cancer shows 1 of several calcified focal liver metastases .*
+
+
+*Axial portal venous-phase CECT in the same patient shows many more metastases . The calcification is more difficult to recognize on this phase of CECT. Calcified metastases can result from several primary tumors, especially mucinous adenocarcinomas of the colon and ovary.*
+
+
+*Axial CECT in a patient with metastatic breast cancer shows a dysmorphic liver with a lobulated and nodular contour . The presence of subtle hypodense lesions within the liver indicates widespread metastases. In response to chemotherapy, some have shrunk in size and become fibrotic, resulting in the appearance of pseudocirrhosis.*
+
+
+*More caudal section in the same patient shows the pseudocirrhosis pattern with widened fissures and peripheral nodularity with capsular retraction .*
+
+
+*Axial T2WI MR in a 44-year-old man with colon cancer shows a total of 4 metastases , 3 of which are seen on this particular section.*
+
+
+*Axial T1WI MR obtained 20 minutes after the IV administration of gadoxetate (Eovist) revealed at least 3 additional metastases . Gadoxetate can make small metastases much more evident than on routine MR or CT evaluation. In this patient, the presence of 6 metastases precluded surgical or ablative therapy.*
+
+
+*Axial NECT in a patient with metastatic breast cancer shows an enlarged low-attenuation liver that might be misinterpreted as steatosis.*
+
+
+*Axial CECT in the same patient shows innumerable hypervascular liver metastases . Ascites is also present. Diffuse metastases that simulate hepatic steatosis can be seen with a variety of primary tumors, including breast, melanoma, and, especially, lymphoma.*
+
+
+*Axial CECT in a 59-year-old woman with breast cancer and liver disfunction shows poorly defined low density replacing most of the right lobe of the liver in a pattern suggesting steatosis or widespread metastases.*
+
+
+*One week later, a PET/CT scan in the same patient was performed. Axial fused PET/CT shows that the abnormal portions of the liver are FDG avid, indicating malignant disease (metastases). PET/CT can be valuable in the detection of subtle or diffuse liver metastases or lymphoma.*
+
+
+*Axial NECT in a patient with metastatic melanoma shows subtle hypodense metastases and others that are hyperdense . Melanoma is one of the few metastases that may be hyperdense to normal-attenuation liver; almost any metastases can be hyperdense to fatty liver.*
+
+
+*Axial CECT in a patient with spontaneous bleeding shows a sentinel clot adjacent to a liver mass , indicating this as the source of bleeding. Also note hemoperitoneum , a relatively rare complication of liver metastases.*
+
+
+*Axial T2 FS MR in a 66-year-old man with chronic lymphocytic leukemia (CLL), note the infiltrative mass with intermediate signal intensity encasing the portal vein without venous invasion.*
+
+
+*Axial postcontrast portal venous-phase T1WI MR in the same patient shows patent vessels penetrating the mass . Lymphoma tends to be soft and may not cause vascular distortion.*
+
+
+*Axial CECT in a patient with diffuse hepatic lymphoma shows innumerable small foci of tumor in the liver and spleen. On NECT, the liver appeared diffusely enlarged and low in attenuation, resembling benign steatosis.*
+
+
+*Axial CECT in a patient with non-Hodgkin lymphoma (NHL) and AIDS shows multifocal hypodense masses in the liver and spleen. Similar masses were present in the kidneys and in multiple nodal groups. AIDS patients and transplant recipients are at high risk for developing NHL.*
+
+
+*Axial CECT in a 42-year-old man with HIV shows a large, heterogeneous mass within the left lobe of the liver .*
+
+
+*Axial T2WI MR in the same patient shows the mass to have intermediate signal intensity .*
+
+
+*Axial venous-phase postcontrast T1WI MR in the same patient shows heterogeneous enhancement in the mass . Biopsy showed diffuse large B-cell lymphoma in this patient with HIV.*
+
+
+*Coronal T1WI MR in a 74-year-old woman with large B-cell lymphoma of the liver shows a soft hypoenhancing mass in the liver with a penetrating vessel .*
+
+
+*Axial CECT shows a large, hypodense mass in the porta hepatis . Note the upstream biliary dilation .*
+
+
+*Coronal CECT in the same patient shows a penetrating vessel . Due to biliary dilation and the mass's location, the mass can be interpreted as a cholangiocarcinoma. However, the penetrating vessel is indicative of a "soft mass." Pathology showed lymphoma.*
+
+
+### Additional Images
+
+
+*Axial CECT shows multiple colorectal metastases having a typical target appearance . Note the obstruction of intrahepatic bile ducts .*
+
+
+*Axial T1WI C+ MR shows a large, heterogeneous, hypointense mass that proved to be metastatic colon cancer.*
+
+
+*Axial T2WI MR shows heterogeneous intensity within the metastatic mass (colon primary) and hyperintensity of surrounding parenchyma, perhaps due to edema &/or compression of liver.*
+
+
+*Axial CECT shows multiple hypodense masses, some of which are almost isodense to liver, in a patient with AIDS and diffuse lymphoma.*
+
+
+*Axial CECT shows necrotic metastasis with a shaggy enhancing wall causing extrinsic compression and obstruction of the left lobe bile ducts. The mass proved to be metastatic colon carcinoma.*
+
+
+*Axial T2WI MR shows bright signal (light bulb sign) in the center of 2 cystic/necrotic metastases from sarcoma of the GI tract.*
+
+
+*Axial NECT shows several focal masses with amorphous calcification, characteristic of mucinous adenocarcinoma (colon primary).*
+
+
+*Axial T1WI MR in a patient with metastatic melanoma shows multiple metastases that have the peculiar feature of being hyperintense on T1WI, which is attributed to the melanin in these lesions. Most metastases are hypo- or isointense to the liver on T1WI.*
+
+
+*Axial T2WI MR in the same patient shows the metastases , but they are nearly isointense to the liver except for foci of necrosis that are hyperintense .*
+
+
+*Axial T1WI C+ MR in a patient with hepatic lymphoma shows a large, heterogeneously hypointense mass .*
+
+
+*Axial T2WI FS MR in the same patient shows that the large solitary mass is heterogeneously hyperintense .*
+
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+---
+title: "Liver"
+docid: "236fb145-0c29-4362-be57-06401bf337aa"
+authors:
+ - key: "b4e1fa52-80a4-4e86-9e6f-beb2fe21629b"
+ value: "Aya Kamaya, MD, FSRU, FSAR"
+breadcrumbs:
+ -
+ name: "Ultrasound"
+ slug: "ultrasound"
+ treeNodeId: "517432cb-177e-4b78-bd9f-4c2e751d132e"
+ -
+ name: "Anatomy"
+ slug: "anatomy"
+ treeNodeId: "43bd9326-ab1c-493e-8d96-8ad0aa58c66a"
+ -
+ name: "Abdomen"
+ slug: "abdomen"
+ treeNodeId: "f90b2a3e-33a7-4ca9-9088-28031711a108"
+ -
+ name: "Liver"
+ slug: "liver"
+ treeNodeId: null
+category: "Ultrasound"
+documentVersionId: "fbd53918-3bd7-401d-bdf4-0df91aa4cf41"
+imageCount: 51
+lastUpdated: "05/06/24"
+pageDescription: "Liver"
+pageKeywords: "Ultrasound, Anatomy, Abdomen, Liver"
+pageTitle: "Liver | STATdx"
+enhancedTitle: "Liver"
+type: "ANATOMY"
+references: true
+breadcrumbs:
+ - "Ultrasound"
+ - "Anatomy"
+ - "Abdomen"
+ - "Liver"
+---
+## GROSS ANATOMY
+
+- ### Overview
+
+
+ - Liver: Largest gland and largest internal organ (average weight: 1,500 g)
+ - Function
+ - Processes all nutrients (except fats) absorbed from gastrointestinal (GI) tract; conveyed via portal vein
+ - Stores glycogen, secretes bile
+ - Relations
+ - Anterior and superior surfaces smooth and convex
+ - Posterior and inferior surfaces indented by colon, stomach, right kidney, duodenum, inferior vena cava (IVC), and gallbladder
+ - Covered by peritoneum except along gallbladder fossa, porta hepatis, and bare area
+ - **Bare area**: Nonperitoneal posterior superior surface where liver abuts diaphragm
+ - **Porta hepatis**: Portal vein, hepatic artery, and bile duct within hepatoduodenal ligament
+ - **Falciform ligament**
+ - Extends from liver to anterior abdominal wall
+ - Separates right and left subphrenic peritoneal recesses (between liver and diaphragm)
+ - Marks plane separating medial and lateral segments of left hepatic lobe
+ - Carries round ligament (ligamentum teres), fibrous remnant of umbilical vein
+ - **Ligamentum venosum**
+ - Remnant of ductus venosus
+ - Separates caudate from left hepatic lobe
+ - **Vascular anatomy (unique dual afferent blood supply)**
+ - **Portal vein**
+ - 75-80% of blood supply to liver
+ - Formed by confluence of superior mesenteric and splenic veins and receives blood from inferior mesenteric, left and right gastric, and cystic veins
+ - Carries nutrients from gut and hepatotrophic hormones from pancreas to liver along with oxygen
+ - Contains 40% more oxygen than systemic venous blood
+ - **Hepatic artery**
+ - 20-25% of blood supply to liver
+ - Liver less dependent than biliary tree on hepatic arterial blood supply
+ - Usually arises from celiac artery
+ - Variations common, including arteries arising from superior mesenteric artery
+ - **Hepatic veins**
+ - Usually 3 (right, middle, and left)
+ - Many variations and accessory veins
+ - Deoxygenated blood from liver returned to IVC
+ - Confluence of hepatic veins just below diaphragm and entrance of IVC into right atrium
+ - **Portal triad**
+ - At all levels of size and subdivision, branches of hepatic artery, portal vein, and bile ducts travel together
+ - Blood flows into hepatic sinusoids from interlobular branches of hepatic artery and portal vein → hepatocytes, which detoxify blood and produce bile
+ - Blood collects into central veins → hepatic veins
+ - Bile collects into ducts → stored in gallbladder and excreted into duodenum
+ - **Segmental anatomy**
+ - 8 hepatic segments
+ - Each receives secondary or tertiary branch of hepatic artery and portal vein
+ - Each drained by its own bile duct (intrahepatic) and hepatic vein branch
+ - Caudate lobe = segment 1
+ - Has independent portal triads and hepatic venous drainage to IVC
+ - Left lobe
+ - Lateral superior = segment 2
+ - Lateral inferior = segment 3
+ - Medial superior = segment 4a
+ - Medial inferior = segment 4b
+ - Right lobe
+ - Anterior inferior = segment 5
+ - Posterior inferior = segment 6
+ - Posterior superior = segment 7
+ - Anterior superior = segment 8
+
+## IMAGING ANATOMY
+
+- ### Internal Contents
+
+
+ - **Capsule**
+ - Reflective Glisson capsule making borders of liver well defined
+ - **Left lobe**
+ - Contains segments 2, 3, 4a, and 4b
+ - Longitudinal scan
+ - Triangular in shape
+ - Rounded upper surface
+ - Sharp inferior border
+ - Transverse scan
+ - Wedge-shaped tapering to left
+ - Liver parenchyma echoes are mid-gray with uniform, sponge-like pattern interrupted by vessels
+ - **Right lobe**
+ - Contains segments 5, 6, 7, and 8
+ - Liver parenchymal echoes similar to left lobe
+ - Sections of right lobe show same basic shape, though right lobe usually larger than left
+ - **Caudate lobe**
+ - Longitudinal scan
+ - Almond-shaped structure posterior to left lobe
+ - Transverse scan
+ - Seen as extension of right lobe
+ - **Portal veins**
+ - Have thicker reflective walls than hepatic veins; portal veins have fibromuscular walls
+ - In hepatic steatosis portal triads often less well visualized
+ - Wall reflectivity also depends on angle of interrogation; portal veins cut at more oblique angle, may have less apparent wall
+ - Can be traced back toward porta hepatis
+ - Normal portal flow is hepatopetal on color Doppler; absent or reversal of flow may be seen in portal hypertension
+ - Normal velocity: 13-55 cm/s
+ - Normal diameter: < 13 mm
+ - Portal waveform has undulating appearance due to transmission of cardiac pressures through sinusoids
+ - Branches run in transverse plane
+ - Hepatic portal vein anatomy is variable
+ - **Hepatic veins**
+ - Appear as echolucent tubular structures within liver parenchyma with no reflective wall: Large sinusoids with thin or absent wall
+ - In hepatic steatosis, hepatic vein walls may appear blurry
+ - Branches enlarge and can be traced toward IVC
+ - Flow pattern has triphasic waveform
+ - Resulting from transmission of right atrial pulsations into veins
+ - A wave: Atrial contraction
+ - S wave: Systole (tricuspid valve moves toward cardiac apex)
+ - D wave: Diastole
+ - Right hepatic vein
+ - Runs in coronal plane between anterior and posterior segments of right hepatic lobe
+ - Middle hepatic vein
+ - Lies in sagittal or parasagittal plane between right and left hepatic lobe
+ - Left hepatic vein
+ - Runs between medial and lateral segments of left hepatic lobe
+ - Frequently duplicated
+ - 1 of 3 major branches of hepatic veins may be absent
+ - Absent right hepatic vein: ~ 6%
+ - Less commonly middle and left hepatic vein
+ - **Hepatic artery**
+ - Flow pattern has low-resistance characteristics with large amount of continuous forward flow throughout diastole
+ - Common hepatic artery usually arises from celiac axis
+ - Classic configuration: 75%
+ - Celiac axis → common hepatic artery → gastroduodenal artery and proper hepatic artery → latter gives rise to right and left hepatic artery
+ - Variations from classic configuration
+ - Common hepatic artery arising from superior mesenteric artery (replaced hepatic artery): 4%
+ - Right hepatic artery arising from superior mesenteric artery (replaced right hepatic artery): 11%
+ - Left hepatic artery arising from left gastric artery (replaced left hepatic artery): 10%
+ - **Bile ducts**
+ - Normal peripheral intrahepatic bile ducts too small to be demonstrated
+ - Normal right and left hepatic ducts measuring few mm usually visible
+ - Normal common duct
+ - Most visible in its proximal portion just caudal to porta hepatis: < 5 mm
+ - Should be measured from inner wall to inner wall
+ - CT unable to visualize inner wall and thus may overestimate caliber
+ - Distal common duct should typically measure < 5-7 mm
+ - In older adults, generalized loss of tissue elasticity with advancing age leads to increase in bile duct diameter but should still remain < 8.5 mm (somewhat controversial)
+ - Post cholecystectomy, slight increase in caliber may be seen: 1- to 2-mm increase
+
+## ANATOMY IMAGING ISSUES
+
+- ### Imaging Recommendations
+
+
+ - Transducer
+ - 2.5- to 6.0-MHz curvilinear or vector transducer
+ - Higher frequency linear transducer (i.e., 7-12 MHz) useful for evaluation of liver capsule and superficial portions of liver
+ - Left lobe
+ - Subcostal window with full inspiration generally most suitable
+ - Right lobe
+ - Subcostal window
+ - Cranial and rightward angulation useful for visualization of right lobe below dome of hemidiaphragm
+ - Can sometimes be obscured by bowel gas
+ - Intercostal window
+ - Usually gives better resolution for parenchyma without influence from bowel gas
+ - Right lobe just below hemidiaphragm may not be visible due to obscuration from lung bases
+ - Important to tilt transducer parallel to intercostal space to minimize shadowing from ribs
+- ### Imaging Pitfalls
+
+
+ - Because of variations of vascular and biliary branching within liver (common), frequently impossible to designate precise boundaries between hepatic segments on imaging studies
+
+## CLINICAL IMPLICATIONS
+
+- ### Clinical Importance
+
+
+ - Liver US often 1st-line imaging modality in evaluation for elevated liver enzymes
+ - Diffuse liver disease, such as hepatic steatosis, cirrhosis, hepatomegaly, hepatitis, and biliary ductal dilatation, well visualized on US
+ - Documentation of patency of portal vein, hepatic vein waveforms, and hepatic arterial velocities helpful in evaluation for etiologies of elevated liver function tests
+ - Shear wave elastography can characterize liver fibrosis with high degree of accuracy
+ - Liver metastases common
+ - Primary carcinomas of colon, pancreas, and stomach commonly metastasize to liver
+ - Portal venous drainage usually results in liver being initial site of metastatic spread from these tumors
+ - Metastases from other non-GI primaries (breast, lung, etc.) commonly spread to liver hematogenously
+ - Primary hepatocellular carcinoma (HCC)
+ - US commonly used for surveillance in patients at risk for developing HCC typically at 6-month intervals
+ - Risk factors include cirrhosis of any etiology and chronic viral hepatitis B in certain populations
+ - Noncirrhotic chronic hepatitis C with stage 3 fibrosis and metabolic dysfunction associated steatohepatitis (MASH) may increase HCC risk but whether surveillance should be performed is uncertain due to lower incidence and cost effectiveness
+
+ c570e2d4-a02b-43b3-a7ac-e59926ba2280
+
+## References
+
+## Selected References
+
+1. [Expert Panel on Gastrointestinal Imaging et al: ACR Appropriateness Criteria® right upper quadrant pain. J Am Coll Radiol. 16(5S):S235-43, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=31054750%5Bpmid%5D)
+1. [Revzin MV et al: Optimizing image quality when evaluating blood flow at Doppler US: a tutorial. Radiographics. 39(5):1501-23, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=31398088%5Bpmid%5D)
+1. [Rodgers SK et al: Role of US LI-RADS in the LI-RADS algorithm. Radiographics. 39(3):690-708, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=31059393%5Bpmid%5D)
+1. [Tse JR et al: Performance of hepatic artery velocity in evaluation of causes of markedly elevated liver tests. Ultrasound Med Biol. 44(11):2233-40, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=30143340%5Bpmid%5D)
+1. [Elsayes KM et al: A comprehensive approach to hepatic vascular disease. Radiographics. 37(3):813-36, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28430541%5Bpmid%5D)
+1. [Kwo PY et al: ACG clinical guideline: evaluation of abnormal liver chemistries. Am J Gastroenterol. 112(1):18-35, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=27995906%5Bpmid%5D)
+1. [Heller MT et al: The role of ultrasonography in the evaluation of diffuse liver disease. Radiol Clin North Am. 52(6):1163-75, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=25444098%5Bpmid%5D)
+1. [McArthur TA et al: The common duct dilates after cholecystectomy and with advancing age: reality or myth? J Ultrasound Med. 32(8):1385-91, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23887947%5Bpmid%5D)
+1. [McNaughton DA et al: Doppler US of the liver made simple. Radiographics. 31(1):161-88, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=21257940%5Bpmid%5D)
+1. [Horrow MM: Ultrasound of the extrahepatic bile duct: issues of size. Ultrasound Q. 26(2):67-74, 2010](http://www.ncbi.nlm.nih.gov/pubmed/?term=20498562%5Bpmid%5D)
+1. [Kruskal JB et al: Optimizing Doppler and color flow US: application to hepatic sonography. Radiographics. 24(3):657-75, 2004](http://www.ncbi.nlm.nih.gov/pubmed/?term=15143220%5Bpmid%5D)
+
+
+## Images
+
+
+### Hepatic Visceral Surface
+
+
+*The anterior surface of the liver is smooth and molds to the diaphragm and anterior abdominal wall. Generally, only the anterior/inferior edge of the liver is palpable on a physical exam. The liver is covered with peritoneum, except for the gallbladder bed, porta hepatis, and bare area. Peritoneal reflections form various ligaments that connect the liver to the diaphragm and abdominal wall, including the falciform ligament, the inferior edge that contains the ligamentum teres, and the obliterated remnant of the umbilical vein.*
+
+
+*The anterior surface of the liver is smooth and molds to the diaphragm and anterior abdominal wall. Generally, only the anterior/inferior edge of the liver is palpable on a physical exam. The liver is covered with peritoneum, except for the gallbladder bed, porta hepatis, and bare area. Peritoneal reflections form various ligaments that connect the liver to the diaphragm and abdominal wall, including the falciform ligament, the inferior edge that contains the ligamentum teres, and the obliterated remnant of the umbilical vein.*
+
+
+*The anterior surface of the liver is smooth and molds to the diaphragm and anterior abdominal wall. Generally, only the anterior/inferior edge of the liver is palpable on a physical exam. The liver is covered with peritoneum, except for the gallbladder bed, porta hepatis, and bare area. Peritoneal reflections form various ligaments that connect the liver to the diaphragm and abdominal wall, including the falciform ligament, the inferior edge that contains the ligamentum teres, and the obliterated remnant of the umbilical vein.*
+
+
+*Graphic shows the liver inverted, which is somewhat similar to the surgeon's view of the upwardly retracted liver. The structures in the porta hepatis include the portal vein (blue), hepatic artery (red), and bile ducts (green). The visceral surface of the liver is indented by adjacent viscera. The bare area is not easily accessible.*
+
+
+### Hepatic Attachments and Relations
+
+
+*The liver is attached to the posterior abdominal wall and diaphragm by the left and right triangular and coronary ligaments. The falciform ligament attaches the liver to the anterior abdominal wall. The bare area is in direct contact with the right adrenal gland, kidney, and inferior vena cava (IVC).*
+
+
+*Posterior view of the liver shows the ligamentous attachments. While these may help to fix the liver in position, abdominal pressure alone is sufficient, as evidenced by orthotopic liver transplantation, after which the ligamentous attachments are lost without the liver shifting position. The diaphragmatic peritoneal reflection is the coronary ligament, of which the lateral extensions are the right and left triangular ligaments. The falciform ligament separates the medial and lateral segments of the left lobe.*
+
+
+### Hepatic Vessels and Bile Ducts
+
+
+*Graphic emphasizes that at every level of branching and subdivision, the portal veins, hepatic arteries, and bile ducts course together, constituting the portal triad. Each segment of the liver is supplied by branches of these vessels. Conversely, hepatic venous branches lie between hepatic segments and interdigitate with the portal triads but never run parallel to them.*
+
+
+### Hepatic Arterial Anatomy
+
+
+*Graphic demonstrates the conventional hepatic arterial supply to the liver. The celiac artery arises at ~ T12 level before dividing into the common hepatic artery, left gastric artery, and splenic artery. The common hepatic artery gives off the gastroduodenal artery inferiorly and becomes the proper hepatic artery, which then divides into the right and left hepatic arteries at the liver hilum. The left hepatic artery courses superiorly and slightly to the left before giving off branches to segments 2-4. In some instances, the segment 4 artery may arise directly from the proper hepatic artery and is then termed the middle hepatic artery. The right hepatic artery divides into anterior and posterior branches, which take an upward vertical course and horizontal course, respectively. The anterior branch gives off arteries supplying segments 5 and 8, while the posterior branches supply segments 6 and 7. Segment 1 (caudate lobe) is typically supplied by small branches of either the right or left hepatic arteries (or both).*
+
+
+### Left Lobe of Liver: Left Hepatic Vein
+
+
+*Transverse US centered at the left hepatic lobe shows the right, middle, and left hepatic veins as they join into the intrahepatic IVC.*
+
+
+*Transverse color Doppler US centered at the confluence of the hepatic veins shows that the flow direction is away from the transducer, directed toward the IVC.*
+
+
+*Spectral tracing of the left hepatic vein near the confluence with the IVC shows a characteristic triphasic waveform pattern, which represents reflection of cardiac motion.*
+
+
+### Longitudinal Left Lobe of Liver
+
+
+*Longitudinal US of the left lobe of the liver shows a triangular-shaped cross section. The heart is partially visualized above the diaphragm.*
+
+
+*Longitudinal US of the left lobe of the liver at the level of the aorta shows the aorta posterior to the liver, the celiac artery, and the superior mesenteric artery arising from the aorta.*
+
+
+*Longitudinal US of the left lobe of the liver shows the left hepatic vein and left portal vein in cross section.*
+
+
+### Transverse Right Lobe of Liver
+
+
+*Transverse US at the level of the hepatic vein confluence shows the right, middle, and left hepatic veins as they join with the IVC posteriorly.*
+
+
+*Transverse US of the liver just below the confluence of the hepatic veins shows the IVC and more peripheral portions of the right and left hepatic veins.*
+
+
+*Transverse US of the right lobe of the liver, centered at the right portal vein, shows the posterior branch of the right portal vein, which is typically directed away from the transducer.*
+
+
+### Right Lobe of Liver: Right Hepatic Vein
+
+
+*Transverse color Doppler US of the right lobe of the liver shows that the right and middle hepatic veins are directed away from the transducer and flowing toward the IVC.*
+
+
+*Spectral tracing of the right hepatic vein shows a typical triphasic waveform with A, S, and D waves representing reflection of cardiac motion in the hepatic veins.*
+
+
+*Spectral tracing of the middle hepatic vein shows a typical triphasic waveform with A, S, and D waves representing reflection of cardiac motion in the hepatic veins.*
+
+
+### Transverse Left Lobe of Liver
+
+
+*Transverse US of the left lobe of the liver is shown centered at the level of the falciform ligament and pancreas.*
+
+
+*Transverse US of the left lobe of the liver is shown.*
+
+
+*Transverse US of the left lobe of the liver is shown centered at the level of the left hepatic vein.*
+
+
+### Main Portal Vein
+
+
+*Longitudinal oblique US is shown centered at the level of the main and right portal veins.*
+
+
+*Longitudinal oblique color Doppler US, centered at the level of the main and right portal veins, shows that flow in the portal vein is directed toward the liver (hepatopetal).*
+
+
+*Longitudinal oblique spectral Doppler US of the main portal vein shows that the flow is hepatopetal with gentle undulation reflecting the cardiac and respiratory cycles.*
+
+
+### Porta Hepatis
+
+
+*Longitudinal oblique spectral tracing of the main hepatic artery shows a typical low-resistance waveform with brisk upstroke and forward diastolic flow. In this case, the hepatic artery velocity is 44 cm/s, which is within normal limits (normal range < 100 cm/s). When measuring velocity, proper angle correction is the key to obtaining accurate velocities.*
+
+
+*Oblique US of the liver, centered at the porta hepatis, shows the common duct anterior to the right hepatic artery and portal vein. Measurement of the hepatic duct should be from inner wall to inner wall. The IVC is seen posterior to the portal vein.*
+
+
+*Oblique color Doppler US of the liver, centered at the porta hepatis, shows that the common duct is anterior to the portal vein, and the right hepatic artery is between these 2 structures. This is the typical anatomy in this location, although anatomic variants of the right hepatic artery may occur in which the hepatic artery may be located anterior to the common duct.*
+
+
+### Left Lobe of Liver: Left Portal Vein
+
+
+*Transverse US of the left lobe of the liver is shown centered at the left portal vein.*
+
+
+*Transverse color Doppler US of the left lobe of the liver is shown centered at the level of the left portal vein. Flow in the left portal vein is directed toward the transducer, indicating that the flow is hepatopetal and therefore normal.*
+
+
+*Spectral tracing of the left portal vein on this transverse pulsed Doppler US shows that the flow is monophasic, directed toward the transducer, with a mildly undulating waveform related to slight transmission of the cardiac cycle, which is a normal appearance for the portal vein.*
+
+
+### Liver Segments
+
+
+*Graphic demonstrates the division of the Couinaud segments of the liver at 4 different levels. The Couinaud segments are defined by the hepatic veins (hepatic vein plane) and the portal veins (portal vein plane).*
+
+
+*Transverse US of the right lobe of liver at the level of the confluence of the hepatic veins shows the right hepatic vein separates segment 7 (superior posterior segment of the right lobe) from segment 8 (superior anterior segment of the right lobe), and the middle hepatic vein separates segment 8 from segment 4a (superior medial segment of the left lobe).*
+
+
+*Transverse US of the right lobe of the liver just below the level of the portal vein shows the right hepatic vein, which demarcates the anterior from posterior segments of the right lobe of the liver. The plane of the middle hepatic vein separates the left lobe from the right lobe. A horizontal plane in line with the main portal vein demarcates the upper from lower liver segments.*
+
+
+*Transverse US of the right lobe of the liver inferiorly at the level of the gallbladder shows segment 5 (inferior anterior segment of the right lobe) and segment 6 (inferior posterior segment of the right lobe). The demarcation between the 2 segments is created by drawing a plane vertically from the right hepatic vein. A vertically oriented plane at the level of the gallbladder and middle hepatic vein separates the right and left lobe of the liver.*
+
+
+*Transverse US of the left lobe of the liver at the level of the confluence of the hepatic veins and IVC shows the left hepatic vein separating segment 2 (superior lateral segment of the left lobe) from segment 4a (superior medial segment of the left lobe).*
+
+
+*Transverse US shows the left lobe of the liver at a level just inferior to the left portal vein. Segment 1 (caudate lobe) abuts the ligamentum venosum, IVC, and left portal vein. The falciform ligament separates segment 3 (inferior lateral segment of the left lobe) from segment 4b (inferior medial segment of the left lobe).*
+
+
+### Additional Images
+
+
+*Longitudinal US of the far left lateral liver shows segment 2 (superior lateral left segment of the left lobe) and segment 3 (inferior lateral left segment of the left lobe) demarcated by the plane of the left portal vein.*
+
+
+*Longitudinal US of the left lobe of the liver just medial to the level of the left hepatic vein (not shown) shows that segment 4a (medial superior segment of left lobe) is separated from segment 4b (medial inferior segment of left lobe) by the horizontal plane of the left portal vein.*
+
+
+*Longitudinal US of the right lobe of the liver just to the right of the middle hepatic vein shows segment 8 (superior anterior segment of right lobe) and segment 5 (inferior anterior segment of right lobe) are separated by the expected horizontal plane of the right portal vein.*
+
+
+*Longitudinal US of the right lobe of the liver just lateral to the right hepatic vein shows segment 6 (posterior inferior segment of the right lobe) and segment 7 (posterior superior segment of the right lobe) separated by the horizontal plane of the right portal vein.*
+
+
+*Transverse US of the right lobe of the liver inferiorly at the level of the gallbladder shows segment 5 (inferior anterior segment of the right lobe) and segment 6 (inferior posterior segment of the right lobe). The demarcation between the 2 segments is created by drawing a plane vertically from the right hepatic vein (not shown). A vertically oriented plane at the level of the gallbladder and middle hepatic vein separates the right and left lobes.*
+
+
+*Longitudinal US of the right lobe of the liver at the level of the right kidney shows segment 6 (posterior inferior segment of the right lobe) and segment 7 (posterior superior segment of the right lobe) separated by the plane of the right portal vein.*
+
+
+*Transverse US of the inferior aspect of the left lobe of the liver at the level of the pancreas is shown. The falciform ligament separates segment 3 (inferior lateral segment of the left lobe) from segment 4b (medial inferior segment of the left lobe).*
+
+
+*Transverse US of the left lobe of the liver at the level of the confluence of the hepatic veins and IVC shows the left hepatic vein separates segment 2 (superior lateral segment of the left lobe) from segment 4a (superior medial segment of the left lobe).*
+
+
+*Transverse US of the left lobe of the liver at a level just inferior to the left portal vein is shown. Segment 1 (caudate lobe) abuts the ligamentum venosum, IVC, and left portal vein. The falciform ligament separates segment 3 (inferior lateral segment of the left lobe) from segment 4b (inferior medial segment of the left lobe).*
+
+
+*Transverse US of the upper right lobe of the liver at the level of the confluence of the hepatic veins shows the right hepatic vein separates segment 7 (superior posterior segment of the right lobe) from segment 8 (superior anterior segment of the right lobe), and the middle hepatic vein separates segment 8 from segment 4a (superior medial segment of the left lobe).*
+
+
+*Transverse US of the right lobe of the liver just below the level of the portal vein shows the right hepatic vein demarcates the anterior from posterior segments of the right lobe. The plane of the middle hepatic vein separates the left lobe from the right lobe. A horizontal plane in line with the main portal vein demarcates the upper from lower liver segments.*
+
+
+*Spectral tracing of the IVC shows a typical triphasic waveform with A, S, and D waves representing reflection of cardiac motion in the IVC.*
+
+
+*Longitudinal color Doppler US of the liver is shown at the level of the IVC.*
+
+
+*Longitudinal US of the right lobe of the liver is shown centered at the level of the IVC.*
+
+
+*Longitudinal oblique US of the liver shows portions of the IVC and the gallbladder.*
+
diff --git a/docs_md/articles/liver_e4fdb09c-d20f-407d-b563-499124541261.md b/docs_md/articles/liver_e4fdb09c-d20f-407d-b563-499124541261.md
new file mode 100644
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+++ b/docs_md/articles/liver_e4fdb09c-d20f-407d-b563-499124541261.md
@@ -0,0 +1,610 @@
+---
+title: "Liver"
+docid: "e4fdb09c-d20f-407d-b563-499124541261"
+authors:
+ - key: "c1df94ab-4a9f-44c4-add7-1f174fb9ac45"
+ value: "Siva P. Raman, MD"
+breadcrumbs:
+ -
+ name: "Gastrointestinal"
+ slug: "gastrointestinal"
+ treeNodeId: "992c2a4d-e0c4-4b82-be00-a05f5f19e3be"
+ -
+ name: "Anatomy"
+ slug: "anatomy"
+ treeNodeId: "8bfe9b67-b11b-4aee-8832-1980400c5ecf"
+ -
+ name: "Hepatobiliary and Pancreas"
+ slug: "hepatobiliary-and-pancreas"
+ treeNodeId: "e81cea27-ee07-499b-879f-d8d910335dc6"
+ -
+ name: "Liver"
+ slug: "liver"
+ treeNodeId: null
+category: "Gastrointestinal"
+documentVersionId: "4bda74d7-c871-427b-a031-378d5e3c6cb4"
+imageCount: 114
+lastUpdated: "06/27/23"
+pageDescription: "Liver"
+pageKeywords: "Gastrointestinal, Anatomy, Hepatobiliary and Pancreas, Liver"
+pageTitle: "Liver | STATdx"
+enhancedTitle: "Liver"
+type: "ANATOMY"
+references: true
+breadcrumbs:
+ - "Gastrointestinal"
+ - "Anatomy"
+ - "Hepatobiliary and Pancreas"
+ - "Liver"
+---
+## GROSS ANATOMY
+
+- ### Overview
+
+
+ - Liver is largest internal body organ (average weight of 1,500 g) with variety of functions, including processing of nutrients absorbed from GI tract (via portal vein), storage of glycogen, and secretion of bile
+ - Gross anatomic relationships
+ - Anterior and superior surfaces (i.e., diaphragmatic surface) are smooth and convex and contact diaphragm
+ - Posterior and inferior surfaces (i.e., visceral surface) are indented by colon, stomach, right kidney, right adrenal gland, duodenum, inferior vena cava (IVC), and gallbladder
+ - Covered by visceral peritoneum except at **gallbladder fossa**, **porta hepatis**, and "**bare area**"****
+ - "**Bare area**": Posterior and superior surface where liver abuts diaphragm and is not covered by peritoneum
+ - Located to right of IVC and contacts IVC and undersurface of diaphragm
+ - **Porta hepatis**: Site of entry/exit of portal vein, hepatic artery, and bile duct
+ - Located immediately anterior to caudate lobe along undersurface of liver
+ - Covered by thick fibrous capsule (**Glisson capsule**)****
+ - Vascular supply: Liver has unique dual blood supply via portal vein and hepatic arteries
+ - **Portal vein**
+ - Accounts for 75-80% of blood supply to liver
+ - Carries nutrients from bowel, hepatotrophic hormones from pancreas, and oxygen (contains 40% more oxygen than systemic venous blood but significantly less oxygen than hepatic artery)
+ - **Hepatic artery**
+ - Accounts for 20-25% of blood supply to liver
+ - Richer in oxygen than portal venous blood but does not contain same nutrients seen in portal venous system
+ - Liver is less dependent than biliary tree on hepatic arterial blood supply
+ - Usually arises from celiac artery, but variations in origin of hepatic artery are very common, such as replaced arteries arising from superior mesenteric artery or left gastric artery
+ - **Hepatic veins**
+ - Usually 3 (right, middle, and left), although there are many variations possible, and accessory veins are common
+ - Return blood to IVC at **confluence of hepatic veins** just below diaphragm and entrance of IVC into heart
+ - **Portal triad**
+ - At all levels of size and subdivision, branches of hepatic artery, portal vein, and bile ducts travel together
+ - Blood flows into hepatic sinusoids from interlobular branches of hepatic artery and portal vein → hepatocytes (detoxify blood and produce bile) → bile enters bile ducts and blood enters central veins → hepatic veins
+ - Segmental anatomy of liver
+ - Older, more traditional division of liver into 4 segments (right anterior and posterior, left medial and lateral) has been supplanted by **Couinaud classification**, which divides liver into 8 segments
+ - More clinically and surgically relevant classification, as each individual segment receives secondary or tertiary branch of hepatic artery and portal vein and is drained by its own bile duct (intrahepatic) and hepatic vein branch
+ - Each segment is functionally independent and can be individually resected
+ - Hepatic artery, portal vein, and bile duct segmental branches enter center of each segment, while hepatic veins are at periphery of segments (and divide segments)
+ - Liver divided in vertical planes by 3 hepatic veins (hepatic vein planes), while portal vein bifurcation divides liver in horizontal plane (portal plane)
+ - Middle hepatic vein divides right and left hepatic lobes (**Cantlie line**)****, while right hepatic vein divides right lobe into anterior and posterior parts and left hepatic vein divides left lobe into medial and lateral parts
+ - Segments are numbered in clockwise order, as if looking at anterior surface of liver
+ - Because of variations of vascular and biliary branching within liver (common), it is frequently impossible to designate precisely boundaries between hepatic segments on imaging studies
+ - Right lobe usually slightly larger than left (~ 60% of total liver volume)
+ - Segment I: Caudate lobe
+ - Unique segment located around intrahepatic IVC, which has independent portal triads and direct hepatic venous drainage to IVC (via small veins)
+ - Left lobe
+ - Lateral superior = segment II (located to left of left hepatic vein and above portal plane)
+ - Lateral inferior = segment III (located to left of left hepatic vein and below portal plane)
+ - Medial superior = segment IVA (located to right of left hepatic vein and above portal plane)
+ - Medial inferior = segment IVB (located to right of left hepatic vein and below portal plane)
+ - Right lobe
+ - Anterior inferior = segment V (located to right of middle hepatic vein and below portal plane)
+ - Posterior inferior = segment VI (located to right of right hepatic vein and below portal plane)
+ - Posterior superior = segment VII (located to right of right hepatic vein and above portal plane)
+ - Anterior superior = segment VIII (located to right of middle hepatic vein and above portal plane)
+ - Major ligaments (double layers of peritoneum, which fix liver to adjacent structures)
+ - **Falciform ligament**: Extends from anterior surface of liver to anterior abdominal wall
+ - Separates right and left **subphrenic peritoneal recesses** (between liver and diaphragm)
+ - Marks plane separating medial and lateral segments of left hepatic lobe
+ - Carries**round ligament** (**ligamentum teres**), fibrous remnant of obliterated umbilical vein
+ - **Coronary ligaments**:**** Connect superior surface of liver to diaphragm (formed by anterior and posterior layers of triangular ligaments uniting together)
+ - Bare area of liver located between 2 leaves of coronary ligament (to right of IVC)
+ - Posterior layer of right coronary ligament a.k.a. hepatorenal ligament
+ - **Triangular ligaments**: Connect superior surface of liver to diaphragm
+ - **Lesser omentum**: Hepatoduodenal ligament and hepatogastric ligament (2 constituents of lesser omentum) connect liver with duodenum and stomach, respectively
+ - Liver also fixed by fibrous tissue to IVC posteriorly
+ - Perihepatic recesses (spaces surrounding liver where fluid can collect)
+ - **Morison pouch (hepatorenal recess)**: Most dependent portion of peritoneal cavity in supine patient between right hepatic lobe and kidney
+ - **Subphrenic space**: Space between liver and diaphragm divided into right and left subphrenic spaces by falciform ligament
+ - **Subhepatic space**:**** Space between undersurface of liver and adjacent transverse colon
+ - Nervous supply
+ - Sympathetic and parasympathetic supply via hepatic nerve plexus (which runs in portal triads)
+ - Sympathetics via celiac plexus and parasympathetics via anterior and posterior vagal trunks
+ - Normal multimodality imaging appearance
+ - CT
+ - Normal liver parenchyma on NECT is ~ 10 HU > spleen (important relationship when trying to diagnose hepatic steatosis)
+ - Liver parenchyma on CECT far more variable making determination of "normal" vs. steatosis much more difficult
+ - No absolute threshold for hyperdense liver (i.e., hemochromatosis, amiodarone effect, etc.), but liver often > 80 HU on NECT or markedly hyperdense compared to spleen
+ - US
+ - Normal liver should be equal or slightly echogenic relative to adjacent right kidney
+ - Measurement from liver dome to right hepatic lobe tip often used in assessment of hepatomegaly with 15.5 cm used as threshold for hepatomegaly (questionable validity)
+ - Liver surface/capsule should be smooth and regular when viewed using high-frequency transducer with surface nodularity suggesting cirrhosis/liver fibrosis
+ - Portal veins have thick, echogenic wall, as opposed to thin wall of hepatic veins
+ - MR
+ - Normal liver slightly hyperintense on T1WI to muscle and kidneys
+ - Normal liver hypointense to spleen, kidneys, and pancreas on T2WI and DWI
+ - Embryology
+ - Liver develops as ventral diverticulum from junction of foregut and midgut
+ - Biliary tree and gallbladder also share this origin from ventral diverticulum
+
+## CLINICAL IMPLICATIONS
+
+- ### Clinical Importance
+
+
+ - Advances in hepatic surgery (tumor resection, transplantation) make it essential to depict lobar and segmental anatomy, volume, blood supply, and biliary drainage as accurately as possible
+ - Combination of standard multiplanar imaging and 3D reconstructions (CT, MR, US) may be necessary for optimal preoperative planning
+ - "Invasive" imaging studies (catheter angiography and percutaneous transhepatic or endoscopic cholangiography) are now usually not necessary due to image quality of CT and MR/MRCP
+ - Segmental Couinaud anatomy is critical for guiding surgical treatment with variety of surgeries (segmentectomy, bisegmentectomy, hepatectomy, extended right/left hepatectomy) based on segmental anatomy
+ - Nonanatomic liver resections not adhering to segmental anatomy termed wedge resection
+ - **Liver metastases are common**and much more common that primary liver malignancies
+ - Primary carcinomas of gastrointestinal tract, such as colon, pancreas, and stomach malignancies are most common
+ - Portal venous drainage usually results in liver being initial site of metastatic spread from these tumors
+ - Arterial-phase imaging critical when evaluating liver for potential metastases from hypervascular primary tumors (e.g., pancreatic neuroendocrine tumor, carcinoid, renal cell carcinoma, etc.), as small metastases may be virtually invisible on portal venous phase
+ - Most common primary liver malignancy is **hepatocellular carcinoma**(a.k.a. **hepatoma**)
+ - Very common malignancy worldwide and most commonly seen in patients with underlying liver cirrhosis as result of chronic viral hepatitis or alcohol abuse
+ - Primary liver malignancies (particularly hepatocellular carcinoma) can invade hepatic vasculature (especially portal venous system)
+ - Arterial-phase imaging critical for detection of small tumors, and MR generally considered superior to CT for assessment of cirrhotic liver
+ - Benign liver lesions are incredibly common and, in most instances, can be easily distinguished from malignant lesions based on characteristic enhancement patterns on multiphase imaging
+ - Most common benign liver lesions include cysts, hemangioma, focal nodular hyperplasia, and hepatic adenoma
+ - Focal fat or focal fatty sparing are common confused for focal liver "masses" and can be easily diagnosed in difficult cases using chemical-shift MR
+
+ db930526-6466-4ab0-8777-a20b5a974bf7
+
+## References
+
+## Selected References
+
+1. [Gómez Varela C et al: "Hot quadrate lobe spot" sign in chronic superior vena cava obstruction. Rev Esp Enferm Dig. 113(11):805-6, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=34315213%5Bpmid%5D)
+1. [Nakamura Y et al: Advanced CT techniques for assessing hepatocellular carcinoma. Radiol Med. 126(7):925-35, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=33954894%5Bpmid%5D)
+1. [Hodler J et al: Focal liver lesions. StatPearls, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=31314381%5Bpmid%5D)
+1. [Mathew RP et al: Liver vascular anatomy: a refresher. Abdom Radiol (NY). 43(8):1886-95, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29696320%5Bpmid%5D)
+1. [Husainy MA et al: Typical and atypical benign liver lesions: A review. Clin Imaging. 44:79-91, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28486156%5Bpmid%5D)
+1. [Favelier S et al: Anatomy of liver arteries for interventional radiology. Diagn Interv Imaging. 96(6):537-46, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=24534562%5Bpmid%5D)
+1. [Pillai AK et al: Portal hypertension: a review of portosystemic collateral pathways and endovascular interventions. Clin Radiol. 70(10):1047-59, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=26188844%5Bpmid%5D)
+1. [Kamaya A et al: Hypervascular liver lesions. Semin Ultrasound CT MR. 30(5):387-407, 2009](http://www.ncbi.nlm.nih.gov/pubmed/?term=19842564%5Bpmid%5D)
+
+
+## Images
+
+
+### Hepatic Visceral Surface
+
+
+*The anterior surface of the liver is smooth and molds to the diaphragm and anterior abdominal wall. Generally, only the anterior/inferior edge of the liver is palpable on physical exam. The liver is covered with peritoneum, except for the gallbladder bed, porta hepatis, and the bare area. Peritoneal reflections form various ligaments that connect the liver to the diaphragm and abdominal wall, including the falciform ligament, the inferior edge of which contains the ligamentum teres, and the obliterated remnant of the umbilical vein.*
+
+
+*The anterior surface of the liver is smooth and molds to the diaphragm and anterior abdominal wall. Generally, only the anterior/inferior edge of the liver is palpable on physical exam. The liver is covered with peritoneum, except for the gallbladder bed, porta hepatis, and the bare area. Peritoneal reflections form various ligaments that connect the liver to the diaphragm and abdominal wall, including the falciform ligament, the inferior edge of which contains the ligamentum teres, and the obliterated remnant of the umbilical vein.*
+
+
+*Graphic shows the liver inverted, somewhat similar to the surgeon's view of the upwardly retracted liver. The structures in the porta hepatis include the portal vein (blue), hepatic artery (red), and the bile ducts (green). The visceral surface of the liver is indented by adjacent viscera. The bare area is not easily accessible.*
+
+
+### Hepatic Attachments and Relations
+
+
+*The liver is attached to the posterior abdominal wall and diaphragm by the left and right triangular ligaments and the coronary ligaments. The falciform ligament attaches the liver to the anterior abdominal wall. The bare area is in direct contact with the right adrenal gland, right kidney, and inferior vena cava (IVC).*
+
+
+*Posterior view of the liver shows the ligamentous attachments. While these may help to fix the liver in position, abdominal pressure alone is sufficient to keep the liver in place, as evidenced by orthotopic liver transplantation, after which the ligamentous attachments are lost without the liver shifting position. The diaphragmatic peritoneal reflection is the coronary ligament whose lateral extensions are the right and left triangular ligaments. The falciform ligament separates the medial and lateral segments of the left lobe.*
+
+
+### Hepatic Vessels and Bile Ducts
+
+
+*Graphic emphasizes that at every level of branching and subdivision, the portal veins, hepatic arteries, and bile ducts course together, constituting the "portal triad." Each segment of the liver is supplied by branches of these vessels. Conversely, hepatic venous branches lie between hepatic segments and interdigitate with the portal triads but never run parallel to them.*
+
+
+### Axial CT, Normal Liver
+
+
+*First of 9 axial CT images shows the confluence of the hepatic veins with the IVC just below the diaphragm and the entrance of the IVC into the right atrium.*
+
+
+*At this level, the portal veins run in a predominantly cephalocaudal direction and bisect the angle made by the hepatic veins. Portal veins generally lie within hepatic segments, while hepatic veins lie between segments.*
+
+
+*The horizontal plane defined by the left portal vein divides the lateral segment into segment 2 (above the vein) and 3 (below the vein).*
+
+
+*The plane of section through the long axis of the right portal vein divides segments 7 and 8 (above) from segments 5 and 6 (below). Note the relationships between the liver, stomach, and pancreas.*
+
+
+*The hepatic artery arises conventionally in this subject from the celiac artery. There is an accessory right hepatic vein that drains directly into the IVC caudal to the confluence of the other hepatic veins.*
+
+
+*Note the fissure for the falciform ligament, which separates the medial and lateral segments of the liver (segment 4 from segments 2 and 3).*
+
+
+*A vertical plane through the falciform ligament separates the medial and lateral segments of the left lobe, while a vertical plane through the gallbladder fossa and middle hepatic vein separates the right and left lobes.*
+
+
+*Note the relationships between the liver and adjacent organs.*
+
+
+*The right lobe of the liver extends much more caudally than the left, occasionally, even into the pelvis. The considerable variability of the shape of the liver makes it difficult to identify hepatomegaly by physical examination alone, especially since only the ventral, inferior edge of the liver can be palpated.*
+
+
+### Portal Venous System
+
+
+*First of 3 CT images emphasizes the portal venous system. This coronal reformation of a CT in the venous phase of imaging shows the superior mesenteric vein and its branches as well as the portal vein. The (arbitrary) thickness and plane of the section exclude the splenic vein and include the iliac arteries.*
+
+
+*Coronal plane through the posterior segments of the liver shows the hepatic artery and portal vein branches to segment 6.*
+
+
+*Thick reconstructed axial section shows a trifurcation pattern of the portal vein in which the left portal vein and the anterior and posterior branches of the right portal vein all arise directly from the main portal vein.*
+
+
+### Liver Segmental Anatomy
+
+
+*First of 2 graphics demonstrates the segmental anatomy of the liver in a somewhat idealized fashion. Segments are numbered in a clockwise direction starting with the caudate lobe (segment I), which cannot be seen on this frontal view. The falciform ligament divides the lateral (segments II and III) from the medial (segments IVa and IVb) left lobe. The horizontal planes separating the superior from the inferior segments follow the course of the right and left portal veins. An oblique vertical plane through the middle hepatic vein, gallbladder fossa, and IVC divides the right and left lobes.*
+
+
+*Posterior view of the liver shows that the caudate is entirely posterior, abutting the IVC, ligamentum venosum, and porta hepatis. A plane through the IVC and gallbladder divides the left and right lobes.*
+
+
+*Graphic demonstrates the division of the Couinaud segments of the liver at 4 different levels of the liver. The Couinaud segments are defined by the hepatic veins (hepatic vein plane) and portal veins (portal vein plane).*
+
+
+*Another graphic focuses on the segments at each of the 4 levels shown in the previous graphic with graphic A being the most inferior (at the level of the portal-splenic confluence) and graphic B being the most superior (at the level of the IVC-hepatic vein confluence). The left hepatic vein divides segments II and III from IVa and IVb, which the plane of the left portal vein divides the superior segments of the left lobe (II and IVa) from the inferior segments (III and IVb). The middle hepatic vein divides segments IVa/b from V and VIII, while the right hepatic vein divides segments V and VIII from VI and VII. The right portal vein divides the superior segments of the right lobe (VII and VIII) from the inferior segments (V and VI).*
+
+
+*Axial CECT through the superior liver demonstrates the right hepatic vein coursing through the right lobe, dividing segments VII and VIII. The right hepatic vein plane also divides segments V and VI below the level of the portal veins.*
+
+
+*A slightly more caudal image (still above the portal vein plane) demonstrates the left hepatic vein plane (line extrapolated through the plane of the left hepatic vein) dividing segments II and IVa of the liver, the middle hepatic vein plane (line extrapolated through the middle hepatic vein) dividing segments IVa and VIII, and the right hepatic vein plane (line extrapolated through the middle hepatic vein) dividing segments VII and VIII.*
+
+
+*More caudal level now demonstrates the portal veins coming into view, which divide the liver into superior and inferior segments. The portal vein plane demarcates the division between segments II and III, IVa and IVb, V and VIII, and VI and VII.*
+
+
+*Axial CECT below the portal vein plane now demonstrates segments III, IVb, VI, and VII. Note the location of the caudate lobe surrounding the IVC and posterior to the fissure of the ligamentum venosum.*
+
+
+*Axial CECT more inferiorly continues to demonstrate the inferior segments of the liver, including III, IVb, V, and VI.*
+
+
+*Final image through the inferior liver now shows that most of the left hepatic lobe has gone out of view in this patient, leaving only the inferior segments of the right hepatic lobe (V and VI) defined by the middle and right hepatic veins.*
+
+
+### Falciform Ligament
+
+
+*First of 3 CECT images shows the falciform ligament in various planes. Coronal reformation through the middle of the liver shows the falciform ligament dividing the medial and lateral segments of the left lobe. The ascending portion of the left portal vein also lies in the falciform ligament.*
+
+
+*A more anterior coronal section shows the ligamentum teres, the obliterated remnant of the umbilical vein, which lies in the falciform ligament before leaving the anteroinferior surface of the liver to extend to the umbilicus.*
+
+
+*This axial CECT section shows the ligamentum teres within the falciform ligament.*
+
+
+### Hepatic Arterial Anatomy Overview
+
+
+*Graphic demonstrates the conventional hepatic arterial supply to the liver. The celiac artery arises at roughly the T12 level before dividing into the common hepatic artery, left gastric artery, and splenic artery. The common hepatic artery gives off the gastroduodenal artery inferiorly and becomes the proper hepatic artery, which then divides into the right and left hepatic arteries at the liver hilum. The left hepatic artery courses superiorly and slightly to the left before giving off branches to segments II-IV. In some instances, the segment IV artery may arise directly from the proper hepatic artery and is then termed the middle hepatic artery. The right hepatic artery divides into anterior and posterior branches, which take a upward vertical course and horizontal course, respectively. The anterior branch gives off arteries supplying segments V and VIII, while the posterior branches supplies segments VI and VII. Segment I (caudate) is typically supplied by small branches of the right or left hepatic arteries (or both).*
+
+
+### Arteriogram, Celiac and Hepatic Arteries
+
+
+*Selective catheterization of the common hepatic artery demonstrates conventional arterial anatomy in which all the hepatic arteries arise from the celiac axis. Variations in hepatic arterial supply are very common and important to recognize, especially if partial hepatic resection is being considered.*
+
+
+### Hepatic Artery Angiogram
+
+
+*Frontal angiogram demonstrates the typical orientations of the anterior and posterior divisions of the right hepatic artery, which parallel those of the bile ducts with the anterior division extending upward in a vertical fashion, while the posterior division extends laterally and horizontally. Also note the course of segmental branches supplying segments II and II arising from the left hepatic artery.*
+
+
+*Hepatic artery angiogram demonstrates the presence of a "middle" hepatic artery arising directly from the proper hepatic artery with a trifurcation configuration (right, left, and middle arising from proper hepatic artery). Segment IV can be supplied either from a segmental branch extending rightward from the left hepatic artery or from a middle hepatic artery directly arising from the proper hepatic artery. Also note the "arch" of the left hepatic artery, a characteristic turn of the left hepatic artery as it overrides the umbilical portion of the left portal vein and then gives off the branches to segments II and III to the left.*
+
+
+### Celiac and Hepatic Arteries
+
+
+*Coronal CECT with MIP reconstruction demonstrates conventional hepatic arterial anatomy. This coronal reformation shows both hepatic arteries arising from the proper hepatic artery which, in turn, arises from the common hepatic artery.*
+
+
+*Axial CECT with MIP reconstruction shows the hepatic and splenic arteries arising from the celiac artery.*
+
+
+### Hepatic and Portal Veins
+
+
+*First of 2 coronal MIP images from a contrast-enhanced MRA shows the major divisions and tributaries of the hepatic and portal veins. Only a few branches of the superior mesenteric vein are included in this plane of section, making it appear artifactually small.*
+
+
+*In this subject, the inferior mesenteric vein joins the confluence of the superior mesenteric and splenic veins. Some of the intravenous contrast medium is still circulating through the arteries, resulting in partial opacification of the aorta.*
+
+
+### Multiplanar CT, Normal Vessels
+
+
+*First of 6 CECT sections through a normal liver is shown. This thick axial plane reconstruction shows the confluence of the hepatic veins.*
+
+
+*Another thick axial reconstructed image shows the intrahepatic portal and hepatic veins.*
+
+
+*Coronal CECT with MIP reconstruction in the arterial phase shows the origins of the celiac and superior mesenteric arteries. The hepatic arteries arise conventionally from branches of the celiac trunk.*
+
+
+*A coronal image from the portal venous phase of enhancement shows the major branches of the portal vein.*
+
+
+*Coronal plane image shows the entry of the right hepatic vein into the IVC. A small accessory right hepatic vein is also present. The thick plane of reconstruction artifactually suggests that the portal vein is entering the IVC.*
+
+
+*Coronal image includes the major tributaries of the portal vein, including the superior and inferior mesenteric veins and the splenic vein. Recirculation of contrast medium results in residual enhancement of some arteries that also lie in this plane of section.*
+
+
+### Axial T2 FS MR
+
+
+*First of 9 axial T2 fat-suppressed MR images shows relatively low signal from the liver parenchyma. Flowing blood appears very dark, while static fluid, such as bile and spinal fluid, appears quite bright.*
+
+
+*The branching pattern of the intrahepatic bile ducts is evident.*
+
+
+*A more caudal section shows the bile ducts becoming larger as they approach the porta hepatis.*
+
+
+*More caudal section shows the usual relation between the bile duct, portal vein, and hepatic artery near the porta hepatis.*
+
+
+*The neck of the gallbladder and cystic duct are seen on this section.*
+
+
+*Section through the porta hepatis shows the hepatic artery and portal vein entering the liver.*
+
+
+*The common duct leaves the liver, descends medial to the 2nd portion of the duodenum, and enters the pancreatic head.*
+
+
+*The vertical course of the bile duct within the pancreatic head is seen well on this image.*
+
+
+*The bile duct is seen just proximal to its confluence with the pancreatic duct and their entry into the pancreaticobiliary ampulla in the duodenum.*
+
+
+### Axial T1 MR, Hepatic Arterial Phase
+
+
+*First of 6 axial T1 MR images obtained during the arterial (portal venous inflow) phase of contrast enhancement shows the hepatic veins as dark, unenhanced structures, while the aorta, arteries, and portal venous branches are bright due to contrast enhancement.*
+
+
+*The portal and hepatic venous branches are well seen on this section.*
+
+
+*A more caudal section again shows the opacified portal vein branches and the unopacified hepatic veins.*
+
+
+*The pancreas, arteries, and portal veins are well opacified on this image.*
+
+
+*Note the intrasegmental position of the portal vein branches, while the hepatic veins lie between segments (in general).*
+
+
+*On these T1 images, static fluid-containing structures, such as the gallbladder and duodenum, appear dark (low signal).*
+
+
+### Normal Axial T1 MR, Venous Phase
+
+
+*First of 3 axial T1 MR images obtained during the hepatic venous phase of enhancement, when all the vascular structures in the liver are of bright signal due to contrast enhancement, is shown. A small cyst is seen adjacent to the right hepatic vein.*
+
+
+*The portal and hepatic vein branches are all enhanced.*
+
+
+*The fissures and paths of the major veins are well identified, aiding in the definition of hepatic segmental anatomy.*
+
+
+### US, Normal Liver
+
+
+*Sagittal US demonstrates the characteristic relationship of the bile duct, portal vein, and hepatic artery in the porta hepatis. The common bile duct consistently runs anterior to the main portal vein in the porta hepatis, an important anatomic relationship when trying to identify the common duct. The right hepatic artery is seen in cross section in this plane.*
+
+
+*Transverse US demonstrates the characteristic appearance of the hepatic veins converging on the IVC in axial cross section. This appearance has been described as the bunny sign, as the hepatic veins resemble the ears of a rabbit.*
+
+
+*Sagittal US demonstrates the fissure of the ligamentum venosum, dividing the caudate lobe from the left hepatic lobe. Replaced or accessory left hepatic arteries arising from the left gastric artery would be visualized in this fissure. The left hepatic vein is seen coursing toward the IVC.*
+
+
+*The fissure of the ligamentum venosum is again visualized, this time in the transverse plane. Note the relationship of the left portal vein, medial and lateral segments of the left lobe, fissure of the ligamentum venosum, caudate, and IVC.*
+
+
+*Transverse US demonstrates a normal appearance of the falciform ligament, an echogenic structure that has not uncommonly been mistaken for an echogenic mass. Segments II and III are seen lateral to the falciform, while segment IVa/b is seen medially.*
+
+
+*Sagittal US demonstrates the classic relationship of the celiac and superior mesenteric arteries in the sagittal plane akin to the appearance of these vessels on a sagittal CT. The superior mesenteric artery is seen diving inferiorly into the mesentery.*
+
+
+### Sonography, Normal Anatomy
+
+
+*Transverse US demonstrates the normal right and left portal veins, both of which have the thick echogenic wall that is characteristic of the portal venous system (and allows portal veins to be easily differentiated from hepatic veins). The left portal vein divides into medial and lateral branches, while the right portal vein divides into anterior and posterior branches.*
+
+
+*Sagittal US through the liver shows its smooth and homogeneous echogenicity with interspersed vessels and small intrahepatic bile ducts. Notice in this image that the right kidney and the liver parenchyma have roughly similar echogenicities. The relationship in echogenicity between these 2 structures is critical in determining whether the liver is abnormally echogenic (suggesting steatosis) or whether the kidney is abnormally echogenic (suggesting chronic medical renal disease).*
+
+
+### Congenital Hypoplasia of Segments
+
+
+*First of 3 axial CECT images shows the colon in the right subphrenic region normally occupied by the anterior and medial segments of the liver. This patient is asymptomatic and has no history of any surgical resection or liver disease. Note the relative absence of tissue lateral to the left portal vein, which lies in the falciform ligament (boundary between the medial and lateral segments). The anterior branch of the right portal vein is absent.*
+
+
+*A surgical clip is present from a prior cholecystectomy during which this congenital hypoplasia of hepatic segments was also noted.*
+
+
+*Congenital hypoplasia usually affects the anterior and medial segments, though any portion of the liver may fail to develop normally. This is one of the common causes of so-called interposition of the colon between the liver and the right hemidiaphragm.*
+
+
+### Hepatic Arterial Variants
+
+
+*In > 40% of individuals, there are variations in the origin and course of the hepatic arteries that differ from the "conventional" depiction. In this graphic, the left hepatic artery arises from the common hepatic artery, proximal to the origin of the gastroduodenal artery. The gallbladder and extrahepatic common bile duct are supplied by the right hepatic artery, as usual. The hepatic artery courses parallel to the portal vein and lies between the vein and the bile duct.*
+
+
+*Graphic shows a completely replaced hepatic artery arising from the superior mesenteric artery. In this setting, the hepatic artery passes through or behind the head of the pancreas and the portal vein and may be inadvertently ligated during pancreatic surgery if this variant is not recognized.*
+
+
+*Graphic depicts a separate origin of the left hepatic artery from the celiac trunk. In addition, the right hepatic artery is "replaced," arising from the superior mesenteric artery. The gastroduodenal and cystic arteries arise from the replaced right hepatic, as is common with this variation.*
+
+
+*Graphic depicts an "accessory" left hepatic artery arising from the left gastric artery. An accessory artery is a vessel in addition to those originating from the conventional depiction. In this case, there is a left hepatic artery arising from the proper hepatic artery as well. All of these variations are common and have major implications for patients undergoing any sort of upper abdominal surgery, especially partial hepatic resection or liver transplantation.*
+
+
+### Replaced Right and Left Hepatic Arteries
+
+
+*First of 3 CECT images in a patient with separately replaced right and left hepatic arteries is shown. Coronal CECT with volume-rendered reconstruction shows the right hepatic artery arising from the superior mesenteric artery. The origin of the left hepatic artery is not shown clearly on this image.*
+
+
+*A frontal film from a conventional catheter angiogram shows the replaced right hepatic artery arising from the superior mesenteric artery.*
+
+
+*Catheter injection of the celiac axis shows the left hepatic artery arising from the left gastric artery. In this subject, the gastroduodenal artery arises directly from the celiac artery. Variations of hepatic arterial anatomy are common and are important to recognize when hepatic transplantation, complex hepatobiliary surgery, or other intervention is being considered.*
+
+
+### Hepatic Artery Variants
+
+
+*Frontal angiogram demonstrates an aberrant right hepatic artery arising from the superior mesenteric artery and taking its typical course upward and to the right.*
+
+
+*Axial CECT demonstrates a small vessel running in the fissure of the ligamentum venosum, a location where an artery should not normally be found. Any artery in this location must represent an aberrant (either accessory or replaced) left hepatic artery arising from the left gastric artery (replaced left hepatic artery in this case).*
+
+
+*Axial CECT demonstrates an artery extending upward toward the liver coursing between the main portal vein and the IVC, a location where the hepatic artery should normally not be visualized. This is the classic location of a replaced right hepatic artery arising from the superior mesenteric artery. The location of an aberrant artery can give away its site of origin, even if the artery is not traced out in its entirety.*
+
+
+### Accessory Right Hepatic Artery
+
+
+*First of 2 volume-rendered, coronal CECT images shows only a small right hepatic artery branch from the common hepatic artery. An accessory right hepatic branch arises from the superior mesenteric artery, a common variant. Note the anastomoses between the accessory right hepatic and gastroduodenal arteries.*
+
+
+*Oblique view of the CTA in the same patient helps to confirm the origin of the accessory hepatic vessel from the superior mesenteric artery.*
+
+
+### Replaced Hepatic Artery
+
+
+*Volume-rendered coronal CECT shows complete replacement of the common hepatic artery from the superior mesenteric artery. Both major hepatic arteries and the gastroduodenal artery arise from the superior mesenteric artery instead of the celiac artery.*
+
+
+*Volume-rendered oblique CECT in the same patient helps to confirm the origin of the entire hepatic arterial system from the superior mesenteric artery.*
+
+
+*Transverse US demonstrates an aberrant hepatic artery coursing between the portal vein and the IVC, representing a replaced right hepatic artery arising from the superior mesenteric artery. With "conventional" anatomy, no artery should normally be seen in this space.*
+
+
+### Portal Vein Variants
+
+
+*MR angiogram (venous phase following IV injection of contrast) shows the most common arrangement of the major tributaries of the portal vein in which the inferior mesenteric vein joins the splenic vein just prior to its confluence with the superior mesenteric vein.*
+
+
+*In this patient, the MRA demonstrates a variant with all 3 major tributaries (portal vein, superior mesenteric vein, and inferior mesenteric vein) coming together at a trifurcated confluence.*
+
+
+### Liver Vessels, Unfavorable for Transplantation
+
+
+*Axial CECT in a potential partial liver donor (from whom the right hepatic lobe would be donated) shows a branch from segment VIII draining into the middle hepatic vein. In the usual incision used for harvesting the right lobe, the liver is divided just to the right of the middle hepatic vein, which would sever the segment VIII branch and require a separate anastomosis to the recipient IVC.*
+
+
+*Coronal CECT shows a large accessory right hepatic vein draining segments V and VI directly into the IVC. If the right lobe were to be transplanted, this would require still another separate anastomosis to the recipient IVC.*
+
+
+*Coronal MIP shows a trifurcation arrangement of the portal vein in which the anterior and posterior branches of the right portal and the left portal vein join at the same point. This variant makes it difficult to transect the right portal vein without jeopardizing the left portal vein. Due to the various vascular anatomic variants demonstrated by CT in this patient, he was judged to not be a candidate for living donation.*
+
+
+### Collateral Flow Through Liver
+
+
+*Axial CECT demonstrates the classic hot quadrate sign in the liver in a patient with known superior vena cava syndrome as a result of collateral flow. This phenomenon is due to collateral blood flow through peridiaphragmatic collateral veins that communicate with hepatic veins and return blood to the IVC. On radionuclide and PET studies, this phenomenon may appear as a hot spot and be confused for a liver tumor.*
+
+
+*Coronal CECT in the same patient nicely demonstrates the right internal mammary collaterals, which bypass the patient's occluded superior vena cava and subsequently enter collaterals in the liver, resulting in this very characteristic perfusion anomaly.*
+
+
+*Axial CECT demonstrates another example of an extensive liver perfusion anomaly resulting from collateral flow in a patient with superior vena cava occlusion.*
+
+
+### Cirrhosis With Portal Hypertension
+
+
+*Axial CECT demonstrates a cirrhotic-appearing liver as well as several stigmata of portal hypertension, including marked splenomegaly and varices. There is chronic-appearing portal vein thrombus with associated calcification, a common feature in patients with portal hypertension.*
+
+
+*Coronal CECT with volume-rendered reconstruction in a known cirrhotic patient demonstrates extensive abdominal wall varices, a finding which has often been described as a caput medusa due to its appearance on clinical examination.*
+
+
+*Axial CECT in a cirrhotic patient demonstrates prominent varices in the upper abdomen. Prominent varices can sometimes be confused for a mass or tumor on noncontrast or arterial-phase imaging, although the diagnosis is obvious in the venous phase.*
+
+
+### Diffuse Hepatic Steatosis
+
+
+*Axial NECT in a patient with hepatic steatosis ("fatty liver") shows that the liver appears darker, or less dense, than the spleen rather than being slightly more dense (higher in attenuation), as would be normal. Generally speaking, a liver parenchymal attenuation < 40 HU on a NECT suggest suggest underlying hepatic steatosis.*
+
+
+*Axial GRE in-phase MR demonstrates homogenous signal throughout the liver in a patient with elevated liver enzymes.*
+
+
+*Axial GRE out-of-phase chemical-shift image in the same patient demonstrates diffuse signal loss throughout the liver compatible with diffuse hepatic steatosis.*
+
+
+### Multifocal Steatosis
+
+
+*Axial CECT shows a geographic area of low attenuation throughout the central and right hepatic lobes. In addition, there are spherical and oval lesions in other segments of the liver. Notice that hepatic vessels course through the low-density lesions without being displaced or occluded. Also note that the low-density lesions are not associated with mass effect on the liver contour nor capsular retraction. Percutaneous biopsy of the right lobe revealed steatohepatitis.*
+
+
+*Axial NECT shows innumerable small hypodense focal liver lesions. Although the patient did not have a known history of malignancy, these findings initially raised concern for potential hepatic metastatic disease.*
+
+
+*Axial out-of-phase GRE MR in the same patient shows selective dropout of signal from each of the lesions, indicating lipid content and essentially confirming the diagnosis of multifocal fatty infiltration (steatosis). Focal steatosis can simulate a primary or metastatic liver tumor, although these entities can generally be easily distinguished using chemical-shift imaging MR.*
+
+
+### Benign Liver Masses
+
+
+*Axial CECT in an asymptomatic patient demonstrates a mass in the right hepatic lobe with peripheral, nodular enhancement, compatible with a benign hemangioma. This appearance is so classic and typical that no further confirmatory imaging or biopsy is needed.*
+
+
+*Axial CECT demonstrates a markedly hypervascular mass with a central scar. The mass was virtually invisible on the venous-phase images (not shown). This constellation of findings is typical for a benign focal nodular hyperplasia.*
+
+
+*Axial CECT demonstrates a hypervascular mass in the right hepatic lobe with central necrosis in a young female patient with a history of oral contraceptive usage. While difficult to make a definitive diagnosis on this single image, this lesion actually demonstrated washout on the delayed-phase images, and there was some clinical concern for potential malignancy. This lesion was ultimately biopsied and shown to represent an hepatic adenoma.*
+
+
+### Liver Metastases
+
+
+*Axial CECT shows numerous heterogeneous masses within all segments of the liver, representing metastases from the patient's primary gastrointestinal stromal tumor. Some of these have a significant central cystic component, consistent with central necrosis.*
+
+
+*Transverse grayscale US demonstrates a solitary ill-defined hypoechoic mass in the liver. While a number of entities could have this appearance (including primary liver tumors), the patient's history of a known lung cancer was the key to the correct diagnosis of a metastasis in this case.*
+
+
+*Axial arterial-phase CECT demonstrates a hypervascular mass in the pancreatic tail representing a primary pancreatic neuroendocrine tumor. There are multiple similarly enhancing lesions in the liver, nicely visualized in this arterial phase of imaging, compatible with pancreatic neuroendocrine tumor metastases. The arterial phase of imaging can be critical in highlighting and detecting hypervascular metastases, particularly when small or subtle.*
+
+
+### Hepatocellular Carcinoma With Tumor Thrombus
+
+
+*Axial arterial-phase CECT demonstrates a typically hypervascular hepatocellular carcinoma in this cirrhotic patient. Note the direct extension of tumor into the right portal vein, a feature that usually precludes liver transplantation in these patients.*
+
+
+*Axial CECT demonstrates extensive infiltrative hepatocellular carcinoma involving both hepatic lobes in a known cirrhotic patient. Note the presence of directly contiguous thrombus in the left portal vein, which demonstrates soft tissue attenuation suggestive of tumor thrombus (rather than the typical low density of bland thrombus).*
+
+
+*Axial T1 C+ arterial-phase MR demonstrates extensive infiltrative hepatocellular carcinoma involving much of the left hepatic love. There is directly contiguous tumor thrombus in the left portal vein, which demonstrates arterial enhancement on these early-phase images.*
+
diff --git a/docs_md/articles/multiple-hypodense-liver-lesions_5178ae9c-1ea9-4e06-9e8a-91e98d8708f6.md b/docs_md/articles/multiple-hypodense-liver-lesions_5178ae9c-1ea9-4e06-9e8a-91e98d8708f6.md
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@@ -0,0 +1,298 @@
+---
+title: "Multiple Hypodense Liver Lesions"
+docid: "5178ae9c-1ea9-4e06-9e8a-91e98d8708f6"
+authors:
+ - key: "6c5a9e0e-9dea-461b-9ad4-c00f5c4c2bbf"
+ value: "Atif Zaheer, MD, FSAR"
+ - key: "e987d3d3-1206-48d6-824b-3347c2968855"
+ value: "Michael P. Federle, MD, FACR"
+breadcrumbs:
+ -
+ name: "Gastrointestinal"
+ slug: "gastrointestinal"
+ treeNodeId: "992c2a4d-e0c4-4b82-be00-a05f5f19e3be"
+ -
+ name: "Differential Diagnosis"
+ slug: "differential-diagnosis"
+ treeNodeId: "b2773887-e8a2-40b6-86b5-3bd2e3ba7c30"
+ -
+ name: "Liver"
+ slug: "liver"
+ treeNodeId: "c1682329-7d88-44f2-bd0f-bccf589e5631"
+ -
+ name: "Modality-Specific Imaging Findings"
+ slug: "modality-specific-imaging-findings"
+ treeNodeId: "2fb11857-1b1b-4498-bdc7-c7776f534b6b"
+ -
+ name: "Computed Tomography"
+ slug: "computed-tomography"
+ treeNodeId: "b2cb8e73-d0ed-4631-a3c9-953336c0a660"
+ -
+ name: "Multiple Hypodense Liver Lesions"
+ slug: "multiple-hypodense-liver-lesions"
+ treeNodeId: null
+category: "Gastrointestinal"
+documentVersionId: "b309d36c-71f1-40cc-8134-efe3dcaa5580"
+imageCount: 29
+lastUpdated: "07/15/22"
+pageDescription: "Multiple Hypodense Liver Lesions"
+pageKeywords: "Gastrointestinal, Differential Diagnosis, Liver, Modality-Specific Imaging Findings, Computed Tomography, Multiple Hypodense Liver Lesions"
+pageTitle: "Multiple Hypodense Liver Lesions | STATdx"
+enhancedTitle: "Multiple Hypodense Liver Lesions"
+type: "DDX"
+breadcrumbs:
+ - "Gastrointestinal"
+ - "Differential Diagnosis"
+ - "Liver"
+ - "Modality-Specific Imaging Findings"
+ - "Computed Tomography"
+ - "Multiple Hypodense Liver Lesions"
+---
+## ESSENTIAL INFORMATION
+
+- ### Key Differential Diagnosis Issues
+
+
+ - On portal venous and delayed-phase CECT, almost all detectable hepatic lesions are hypodense (hypoattenuating)
+ - In order to narrow DDx, need to characterize contents and margins of lesions
+ - e.g., water density = cysts, cystic metastases, polycystic liver, biliary hamartoma
+ - Neoplasms and abscesses have less distinct walls than cysts
+ - Very helpful to compare with NECT and arterial-phase CECT, if available
+ - e.g., contents of cysts and abscesses do not enhance; all (nonnecrotic) tumors do
+ - Lesion that is hyperdense on hepatic arterial phase (HAP) but becomes hypodense on portal venous phase is definitely neoplastic
+ - Hepatic lesions that are "too small to characterize" rarely represent metastases
+ - Lesions that are lower than blood density on NECT rarely represent metastases
+ - Look for hypervascularity surrounding lesions, solid component, nodularity, or perilesional edema
+- ### Helpful Clues for Common Diagnoses
+
+
+ - **Simple Hepatic Cysts**
+ - Commonly are multiple and of variable size
+ - Larger ones will measure water density and have sharply defined walls, no or few septa
+ - Small lesions: Indistinct walls and uncertain density due to volume averaging
+ - Thin CT section minimizes this problem
+ - **Hepatic Cavernous Hemangioma**
+ - Multiple lesions are not rare
+ - May be innumerable and in other organs and body wall (Kasabach-Merritt syndrome)
+ - CT criteria: Blood pool density on NECT; nodular peripheral enhancement, isodense to blood pool on CECT
+ - Flash-filling hemangiomas may have surrounding perfusion change on arterial phase
+ - **Metastases and Lymphoma, Hepatic**
+ - Most common cause for multiple solid, hypodense lesions in adult
+ - Most common primary sites: Colorectal, pancreas, breast, lung, stomach, ocular
+ - Most common histology: Adenocarcinoma, squamous cell, neuroendocrine, lymphoma, sarcoma
+ - Colon cancer comprises 50% of cases of metastatic cancer
+ - Almost all are hypo- or isodense to liver on portal venous and delayed imaging
+ - Many will have hypervascular rim on HAP (not considered hypervascular)
+ - Even hypervascular metastases washout to become hypodense on venous and delayed imaging
+ - **Biliary Hamartoma**
+ - Usually multiple to innumerable, nearly uniform in size, < 15 mm in diameter
+ - Fibrotic tissue in walls may cause nodular periphery on CECT or CEMR and echogenicity on US
+ - Starry-sky appearance on MRCP
+ - Biliary hamartomas are common cause of multiple "too small to characterize" lesions
+ - **Autosomal Dominant Polycystic Disease, Liver**
+ - Innumerable cysts, many with calcified walls and higher density (blood)
+ - Cysts vary in size and often distort and enlarge liver
+ - Associated cysts in kidneys and other organs; family history
+ - **Multifocal Fatty Infiltration**
+ - May closely simulate metastases
+ - Often has perivascular distribution or follows fissures
+ - Blood vessels traverse lesion without mass effect
+ - Definitive diagnosis by in- and opposed-phase GRE MR
+ - May be seen following severe acute pancreatitis or post pancreatic resection
+ - **Hepatic Pyogenic Abscesses**
+ - Pyogenic are more common and multiple than with amebic or hydatid
+ - Associated pleural effusion, atelectasis, portal vein thrombophlebitis
+ - Usually multiseptate or cluster of grapes appearance
+ - **Hepatocellular Carcinoma**
+ - Usually in cirrhotic liver or one damaged by chronic hepatitis
+ - Associated signs of portal hypertension, venous invasion
+ - Most lesions are heterogeneously hypervascular on arterial-phase CECT
+ - Washout to hypodensity on venous and delayed imaging
+- ### Helpful Clues for Less Common Diagnoses
+
+
+ - **Opportunistic Infection, Hepatic**
+ - Innumerable "microabscesses" in immunocompromised patients
+ - *Candida* is most common organism
+ - Other fungi, tuberculosis, and other organisms are less common
+ - Usually multiple to innumerable
+ - Irregular margins; size from few mm to ~ 15 mm
+ - **Regenerative or Dysplastic Nodules in Cirrhosis**
+ - Patients with severe cirrhosis
+ - Look for arterial enhancement and washout to exclude hepatocellular carcinoma
+ - Diffuse, lace-like, thick bands of fibrosis
+ - Fatty changes: Diffuse or geographic areas of low attenuation
+ - Usually limited to alcoholic hepatitis with early cirrhosis
+ - **Hepatic Adenoma**
+ - Uncommon disease, but lesions are often multiple; may be innumerable (adenomatosis)
+ - Larger lesions usually heterogeneous due to presence of fat, hemorrhage, or necrosis
+ - Associated history of oral contraceptives, anabolic steroids, glycogen storage disease
+ - Obesity and steatosis predispose to multiplicity and rapid growth of adenomas
+ - MR evidence of capsule, intralesional lipid, and hemorrhage favor adenoma
+ - **Hepatic****Amebic Abscesses**
+ - Usually in right lobe (70-80%); usually peripheral
+ - Usually isolated or no more than a few
+ - Complex fluid contents with distinct capsule
+ - Imaging and demographics suggest Dx
+ - Easily confirmed by serology
+- ### Helpful Clues for Rare Diagnoses
+
+
+ - **Hepatic Angiomyolipoma**
+ - Multiple lesions are seen almost exclusively in tuberous sclerosis syndrome
+ - Only 50% of hepatic angiomyolipomas have substantial fat component
+ - Hepatic angiomyolipomas in kidney; cystic lesions in lungs
+ - **Epithelioid Hemangioendothelioma**
+ - Multiple, peripheral, confluent hepatic masses
+ - Often with target appearance and overlying hepatic capsular retraction
+ - **Caroli Disease**
+ - Multiple cyst-like spaces within liver that communicate with biliary tree
+ - Central dot sign = portal venous radicle wrapped by ectatic ducts
+- ### Other Essential Information
+
+
+ - In nononcology patient, appearance of benign lesions on CECT is often sufficiently characteristic to obviate additional evaluation
+ - Oncology patient: Most metastases have characteristic appearance and biological behavior (e.g., interval growth or regression on therapy) to not require additional imaging evaluation
+ - Cysts, hemangiomas, and multifocal steatosis have characteristic appearance on MR, allowing confident diagnosis
+ - Biliary hamartomas are markedly underdiagnosed by radiologists
+ - Comprise many "too small to characterize" lesions seen on CT
+- ### Alternative Differential Approaches
+
+
+ - Lesions that may be hyperdense on arterial phase but hypo- or isodense on portal venous and delayed phase
+ - Benign
+ - Adenomas, focal nodular hyperplasia (FNH), nodular regenerative hyperplasia
+ - Different types of benign lesions may coexist (cysts, hemangiomas, FNH, adenomas)
+ - Malignant
+ - Hepatocellular carcinoma and metastases
+ - Especially from neuroendocrine, renal, sarcoma primaries, and, occasionally, from primary tumors in ovary, choriocarcinoma, breast, melanoma
+
+
+## Images
+
+
+### Selected Images
+
+
+**Simple Hepatic Cysts**
+*Axial CECT shows multiple water density hepatic lesions with no discernible walls. One of the larger cysts has a thin septum , but there is no nodularity of the wall.*
+
+
+**Simple Hepatic Cysts**
+*Axial CECT shows multiple water density hepatic lesions with no discernible walls. One of the larger cysts has a thin septum , but there is no nodularity of the wall.*
+
+
+**Hepatic Cavernous Hemangioma**
+*Axial CECT shows 2 hepatic masses , each with characteristic peripheral nodular enhancement isodense with blood vessels.*
+
+
+**Metastases and Lymphoma, Hepatic**
+*Axial CECT in a woman with metastatic ovarian carcinoma shows multiple hypodense liver metastases . The lesions are almost cystic in appearance, reflecting the cystic nature of the primary tumor.*
+
+
+**Metastases and Lymphoma, Hepatic**
+*Axial CECT in a patient with metastatic squamous cell carcinoma shows 1 of several near-water density hepatic lesions that may be compared with the appearance of a simple renal cyst . Indications that the hepatic lesions are not simple cysts include the subtle wall thickening and irregularity.*
+
+
+**Metastases and Lymphoma, Hepatic**
+*Axial CECT in a patient with metastatic pancreatic carcinoma shows multiple hypodense liver metastases with poorly defined margins. Also note bilateral adrenal metastases .*
+
+
+**Metastases and Lymphoma, Hepatic**
+*Axial CECT in a patient with AIDS and hepatic lymphoma shows multiple hypodense hepatic masses.*
+
+
+**Biliary Hamartoma**
+*Axial CECT in an asymptomatic 57-year-old man shows innumerable small "cystic lesions" throughout the liver, ranging in size from 2-15 mm. The lesions are often not perfectly spherical, and many have visible nodular enhancement within their walls.*
+
+
+**Biliary Hamartoma**
+*US in the same patient shows only the lesions > 10 mm as cystic structures , whereas the smaller lesions are actually hyperechoic . These are typical imaging features of biliary hamartomas.*
+
+
+**Autosomal Dominant Polycystic Disease, Liver**
+*Axial CECT shows innumerable hepatic cysts of varying size with only small cysts noted in normally functioning kidneys.*
+
+
+**Hepatic Pyogenic Abscess**
+*Axial CECT in an older woman with ascending cholangitis shows a large, multiseptate mass , typical for pyogenic abscess. This was confirmed and treated with percutaneous catheter placement.*
+
+
+**Multifocal Fatty Infiltration**
+*Axial CECT in a 36-year-old man shows multifocal, hypodense lesions that predominantly lie in a perivascular distribution, surrounding hepatic vessels . Note that the vessels are not narrowed or displaced by the hypodense lesions.*
+
+
+**Multifocal Fatty Infiltration**
+*Axial opposed-phase T1 GRE MR in the same patient clearly shows signal dropout from each of the perivascular foci of steatosis , meaning the diagnosis can be made with confidence. Axial in-phase T1 GRE MR showed no apparent lesions.*
+
+
+**Hepatocellular Carcinoma**
+*Axial arterial-phase CECT in a 55-year-old man shows multiple hypervascular masses . Also note an enhancing tumor within the left portal vein .*
+
+
+**Hepatocellular Carcinoma**
+*Axial portal venous-phase CECT in the same patient shows multiple lesions that are hypodense to the background liver, indicating tumor washout. Also note hypodense tumor within the dilated left portal vein.*
+
+
+**Hepatic Sarcoidosis**
+*Axial CECT shows numerous hypodense nodules or small masses in the liver and spleen . On this and other sections, CT also showed upper abdominal and thoracic lymphadenopathy . Biopsy confirmed sarcoidosis.*
+
+
+**Opportunistic Infection, Hepatic**
+*Axial CECT shows innumerable small (< 2 cm), irregular hypodense lesions in this febrile, immunocompromised patient. Biopsy confirmed Candida microabscesses.*
+
+
+**Opportunistic Infection, Hepatic**
+*Axial CECT in a young woman with acute leukemia and fever shows several small, spherical, hypodense hepatic lesions that have alternating concentric circles of hypodense and hyperdense rings (target sign). Biopsy confirmed Candida abscesses.*
+
+
+**Opportunistic Infection, Hepatic**
+*Longitudinal US in the same patient shows more lesions , including smaller lesions with central echogenic foci and through transmission , indicative of fluid content. Thin-needle US-guided aspiration confirmed Candida infection.*
+
+
+**Hepatic Amebic Abscesses**
+*Axial CECT shows multiple hypodense, encapsulated hepatic masses . In this febrile, Hispanic immigrant, amebic abscess was considered and confirmed by serology. Amebic abscesses are rarely so numerous as in this case.*
+
+
+**Hepatic Hydatid Cysts**
+*Coronal CECT in a young Jordanian immigrant with fever shows 2 large, multiseptate hepatic masses . Note the characteristic daughter cysts within one of the lesions.*
+
+
+**Regenerative or Dysplastic Nodules in Cirrhosis**
+*Axial CECT in a patient with severe cirrhosis and stigmata of portal hypertension shows innumerable hypodense, regenerating/dysplastic nodules present.*
+
+
+**Hepatic Adenoma**
+*Axial CECT shows multiple hypodense but enhancing masses with encapsulation . Very low-density foci suggest fat content, which was confirmed by MR within these multiple hepatic adenomas.*
+
+
+**Hepatic Angiomyolipoma**
+*Axial CECT shows fat density masses in the liver and kidneys in this patient with tuberous sclerosis.*
+
+
+**Hepatic Angiomyolipoma**
+*Axial CECT shows fat density masses within the liver and kidneys in this patient with tuberous sclerosis and angiomyolipomas.*
+
+
+**Epithelioid Hemangioendothelioma**
+*Axial CECT shows multiple peripheral lesions with a target appearance and retraction of the overlying hepatic capsule and a characteristic appearance of epithelioid hemangioendothelioma.*
+
+
+**Caroli Disease**
+*Axial CECT shows multiple cystic lesions in the liver. Note the central dot sign , representing the hepatic artery enveloped by the cystic bile duct dilations.*
+
+
+### Additional Images
+
+
+**Hepatic Sarcoidosis**
+*Axial CECT shows innumerable hypodense lesions in liver and spleen along with upper abdominal lymphadenopathy .*
+
+
+**Opportunistic Infection, Hepatic**
+*Axial CECT shows multiple very small, hypodense lesions in a woman with breast cancer. Needle aspiration confirmed Candida microabscesses.*
+
+
+**Epithelioid Hemangioendothelioma**
+*Axial CECT shows multiple peripheral (and central) hypodense lesions, many of which are confluent. Note flattening or retraction of capsule .*
+
diff --git a/results.json b/results.json
index 0a68b28..19269ff 100644
--- a/results.json
+++ b/results.json
@@ -1,4 +1,349 @@
[
+ {
+ "path": "docs_md/articles/cystic-hepatic-mass_85bb9a0b-2d25-457d-a131-20ff07cb552b.md",
+ "title": "Cystic Hepatic Mass",
+ "docid": "85bb9a0b-2d25-457d-a131-20ff07cb552b",
+ "breadcrumbs": [
+ "Gastrointestinal",
+ "Differential Diagnosis",
+ "Liver",
+ "Generic Imaging Patterns",
+ "Cystic Hepatic Mass"
+ ],
+ "authors": [
+ {
+ "key": "6c5a9e0e-9dea-461b-9ad4-c00f5c4c2bbf",
+ "value": "Atif Zaheer, MD, FSAR"
+ },
+ {
+ "key": "e987d3d3-1206-48d6-824b-3347c2968855",
+ "value": "Michael P. Federle, MD, FACR"
+ }
+ ],
+ "pageKeywords": "Gastrointestinal, Differential Diagnosis, Liver, Generic Imaging Patterns, Cystic Hepatic Mass",
+ "reasons": [
+ "Content"
+ ],
+ "snippet": "...Often multiple, of varying sizes - **Autosomal Dominant Polycystic Disease, Liver** - Many cysts of varying sizes - Intracyst...",
+ "linked_info": {
+ "anatomy": {
+ "exists": false,
+ "links": []
+ },
+ "differential": {
+ "exists": false,
+ "links": []
+ }
+ },
+ "is_cached": true
+ },
+ {
+ "path": "docs_md/articles/hepatic-cyst_e525e5da-75e8-432c-b398-cb3d18e97771.md",
+ "title": "Hepatic Cyst",
+ "docid": "e525e5da-75e8-432c-b398-cb3d18e97771",
+ "breadcrumbs": [
+ "Gastrointestinal",
+ "Diagnosis",
+ "Liver",
+ "Benign Neoplasms and Tumor-Like Conditions",
+ "Hepatic Cyst"
+ ],
+ "authors": [
+ {
+ "key": "6c5a9e0e-9dea-461b-9ad4-c00f5c4c2bbf",
+ "value": "Atif Zaheer, MD, FSAR"
+ },
+ {
+ "key": "e987d3d3-1206-48d6-824b-3347c2968855",
+ "value": "Michael P. Federle, MD, FACR"
+ }
+ ],
+ "pageKeywords": "Gastrointestinal, Diagnosis, Liver, Benign Neoplasms and Tumor-Like Conditions, Hepatic Cyst",
+ "reasons": [
+ "Content"
+ ],
+ "snippet": "...lly < 10 - When > 10, consider autosomal dominant polycystic liver disease (ADPLD) or biliary hamartomas - Sharply defined margins, thin...",
+ "linked_info": {
+ "anatomy": {
+ "exists": false,
+ "links": []
+ },
+ "differential": {
+ "exists": true,
+ "links": [
+ {
+ "title": "Autosomal Dominant Polycystic Liver Disease",
+ "docid": "c8256fa3-0694-412c-bd0f-8869f336ad90"
+ },
+ {
+ "title": "Cystic or Necrotic Metastases",
+ "docid": "248db898-197a-4555-a14d-eef5ca2f8967"
+ },
+ {
+ "title": "Mucinous Cystic Neoplasm of Liver",
+ "docid": "0aea34ce-3322-4284-a6f3-6c79e3359520"
+ },
+ {
+ "title": "Biliary Hamartomas",
+ "docid": "1b525344-ad66-4381-9ca9-3fb11172744f"
+ },
+ {
+ "title": "Hepatic Cavernous Hemangioma",
+ "docid": "b6861694-7bb0-4730-860d-4c78c1cdb38b"
+ },
+ {
+ "title": "Biloma",
+ "docid": "171c7cd5-66b3-4d4d-9dd7-32300312fb5d"
+ },
+ {
+ "title": "Hepatic Pyogenic Abscess",
+ "docid": "c0b88320-bb06-4495-9830-70ea36e6cd9c"
+ },
+ {
+ "title": "Hydatid (Echinococcal) Disease",
+ "docid": "2bbda180-2b69-44fa-bd95-393c1531056d"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "85bb9a0b-2d25-457d-a131-20ff07cb552b"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "c18aa6ea-d21c-4e66-af83-4d4b168dc014"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "5e6be44f-07d3-4569-abe3-798d7513fe41"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "5178ae9c-1ea9-4e06-9e8a-91e98d8708f6"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "2efd9ba2-d744-44ac-844f-d706d5cdad85"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "a4d9d25d-ae2a-486a-9709-10dbb62e0361"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "70fea150-3a7b-4f5c-a8f5-9ecc5c6df6e4"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "5a0f58f1-beb9-459d-8246-83d6ddaf76db"
+ }
+ ]
+ }
+ },
+ "is_cached": true
+ },
+ {
+ "path": "docs_md/articles/hepatic-metastases-and-lymphoma_248db898-197a-4555-a14d-eef5ca2f8967.md",
+ "title": "Hepatic Metastases and Lymphoma",
+ "docid": "248db898-197a-4555-a14d-eef5ca2f8967",
+ "breadcrumbs": [
+ "Gastrointestinal",
+ "Diagnosis",
+ "Liver",
+ "Malignant Neoplasms",
+ "Hepatic Metastases and Lymphoma"
+ ],
+ "authors": [
+ {
+ "key": "6c5a9e0e-9dea-461b-9ad4-c00f5c4c2bbf",
+ "value": "Atif Zaheer, MD, FSAR"
+ },
+ {
+ "key": "e987d3d3-1206-48d6-824b-3347c2968855",
+ "value": "Michael P. Federle, MD, FACR"
+ }
+ ],
+ "pageKeywords": "Gastrointestinal, Diagnosis, Liver, Malignant Neoplasms, Hepatic Metastases and Lymphoma",
+ "reasons": [
+ "Content"
+ ],
+ "snippet": "...hepatic mass without vascular occlusion or thrombosis - Liver metastases - Hypovascular metastases: Low-density center with peripheral r...",
+ "linked_info": {
+ "anatomy": {
+ "exists": true,
+ "links": [
+ {
+ "title": "Anatomy Document",
+ "docid": "e4fdb09c-d20f-407d-b563-499124541261"
+ },
+ {
+ "title": "Anatomy Document",
+ "docid": "236fb145-0c29-4362-be57-06401bf337aa"
+ }
+ ]
+ },
+ "differential": {
+ "exists": true,
+ "links": [
+ {
+ "title": "Multiple Hepatic Cysts",
+ "docid": "e525e5da-75e8-432c-b398-cb3d18e97771"
+ },
+ {
+ "title": "Multifocal Fatty Infiltration (Steatosis)",
+ "docid": "de725ab5-ee7d-4629-85f7-4b5bb6ca13b9"
+ },
+ {
+ "title": "Multiple Hemangiomas",
+ "docid": "b6861694-7bb0-4730-860d-4c78c1cdb38b"
+ },
+ {
+ "title": "Multiple Liver Abscesses",
+ "docid": "c0b88320-bb06-4495-9830-70ea36e6cd9c"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "85bb9a0b-2d25-457d-a131-20ff07cb552b"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "c18aa6ea-d21c-4e66-af83-4d4b168dc014"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "59f30739-548e-4501-96dc-57e48a5386cb"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "caf98eea-48d6-4a0f-a747-1c162f945fed"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "1bbbb785-e1e1-4f52-9a37-6ef333c7ec55"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "6b7939de-9506-4ee2-944d-65766e04e5cf"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "5e6be44f-07d3-4569-abe3-798d7513fe41"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "552e0b3f-a4c2-4195-a8de-87c32b6fd96b"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "37b0a03f-b726-4b43-9812-45409af23350"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "2efd9ba2-d744-44ac-844f-d706d5cdad85"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "70fea150-3a7b-4f5c-a8f5-9ecc5c6df6e4"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "723cf3ce-66c2-491a-8331-49f5aaf8a054"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "5a0f58f1-beb9-459d-8246-83d6ddaf76db"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "5178ae9c-1ea9-4e06-9e8a-91e98d8708f6"
+ },
+ {
+ "title": "Asymmetric Dilation of Intrahepatic Bile Ducts",
+ "docid": "54bd67f4-bbad-48a9-9baa-96d727b34aef"
+ },
+ {
+ "title": "Biliary Strictures, Multiple",
+ "docid": "7d85bca2-14b8-4a55-8ba4-ded2672122d6"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "482d9968-2c80-4ea1-9562-8dfbabb4e517"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "db4385a3-b724-4ad2-91b1-44332d70914f"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "69ce0141-f34e-49d9-a70f-e4da8af391f7"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "325a4527-e4dc-485b-9f89-2cfd5f0a311c"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "b93336e2-9006-4f95-92c1-10276069dcc0"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "fa37a33a-89b1-47a1-88dd-aac411492aaf"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "6805354c-8246-45dc-aa61-c84f0dab6d16"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "75912629-c3e6-4960-9e4d-513fa23779ac"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "1c5f721d-871a-4ce1-858b-5144e4802724"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "eec74ad0-7cc0-49e7-8f1f-1e7608451d94"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "be3461de-f44d-4477-8f5b-e62a74b8b691"
+ },
+ {
+ "title": "Right Upper Quadrant Pain",
+ "docid": "33f29d78-0099-4ee9-85da-d0c70c1e0ce6"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "7aaa83d3-f945-4be0-8146-e9f49e381e7e"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "7825b51a-c690-4d68-b456-4d9ae4214f45"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "cf8a471a-3174-43e2-98a5-dce76a3512e5"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "fa133894-b0a5-43cf-8b6d-8445f1281374"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "f17bee75-f8ce-4073-92b0-c086f86ae808"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "a8bc808b-8270-46c1-beb4-9c380238e211"
+ },
+ {
+ "title": "Differential Diagnosis",
+ "docid": "adbcbcd1-d849-45a5-ba3e-01ac759daca2"
+ }
+ ]
+ }
+ },
+ "is_cached": true
+ },
{
"path": "docs_md/articles/autosomal-dominant-polycystic-liver-disease_c8256fa3-0694-412c-bd0f-8869f336ad90.md",
"title": "Autosomal Dominant Polycystic Liver Disease",
@@ -79,6 +424,46 @@
}
]
}
- }
+ },
+ "is_cached": true
+ },
+ {
+ "path": "docs_md/articles/multiple-hypodense-liver-lesions_5178ae9c-1ea9-4e06-9e8a-91e98d8708f6.md",
+ "title": "Multiple Hypodense Liver Lesions",
+ "docid": "5178ae9c-1ea9-4e06-9e8a-91e98d8708f6",
+ "breadcrumbs": [
+ "Gastrointestinal",
+ "Differential Diagnosis",
+ "Liver",
+ "Modality-Specific Imaging Findings",
+ "Computed Tomography",
+ "Multiple Hypodense Liver Lesions"
+ ],
+ "authors": [
+ {
+ "key": "6c5a9e0e-9dea-461b-9ad4-c00f5c4c2bbf",
+ "value": "Atif Zaheer, MD, FSAR"
+ },
+ {
+ "key": "e987d3d3-1206-48d6-824b-3347c2968855",
+ "value": "Michael P. Federle, MD, FACR"
+ }
+ ],
+ "pageKeywords": "Gastrointestinal, Differential Diagnosis, Liver, Modality-Specific Imaging Findings, Computed Tomography, Multiple Hypodense Liver Lesions",
+ "reasons": [
+ "Content"
+ ],
+ "snippet": "...- e.g., water density = cysts, cystic metastases, polycystic liver, biliary hamartoma - Neoplasms and abscesses have less distinct...",
+ "linked_info": {
+ "anatomy": {
+ "exists": false,
+ "links": []
+ },
+ "differential": {
+ "exists": false,
+ "links": []
+ }
+ },
+ "is_cached": true
}
]
\ No newline at end of file
diff --git a/scrapers/capture_passive_playwright_async.py b/scrapers/capture_passive_playwright_async.py
index ca854e6..764566d 100644
--- a/scrapers/capture_passive_playwright_async.py
+++ b/scrapers/capture_passive_playwright_async.py
@@ -113,6 +113,9 @@ async def run_capture(args):
else:
context = await browser_type.launch_persistent_context(user_data_dir=args.profile, headless=args.headless)
+ context_closed = asyncio.Event()
+ context.on('close', lambda ctx: context_closed.set())
+
page = await context.new_page()
async def attempt_autologin(page, username: str, password: str, post_login_selector: str, wait_after: float = 1.0):
@@ -469,6 +472,48 @@ async def run_capture(args):
# Start heartbeat
hb_task = asyncio.create_task(heartbeat())
+ # Start control server
+ async def open_in_playwright(target_url: str):
+ try:
+ pg = context.pages[0] if context.pages else await context.new_page()
+ await pg.goto(target_url)
+ print(f"{now_ts()}\tCONTROL\tOpened URL: {target_url}")
+ except Exception as e:
+ print(f"{now_ts()}\tCONTROL\tError opening URL: {e}")
+
+ async def handle_client(reader, writer):
+ try:
+ data = await reader.read(4096)
+ request_str = data.decode('utf-8', errors='ignore')
+ lines = request_str.split('\r\n')
+ if lines:
+ req_line = lines[0]
+ parts = req_line.split(' ')
+ if len(parts) >= 2:
+ method, path = parts[0], parts[1]
+ if path.startswith('/open'):
+ from urllib.parse import urlparse, parse_qs
+ query = urlparse(path).query
+ params = parse_qs(query)
+ target_url = params.get('url', [None])[0]
+ if target_url:
+ asyncio.create_task(open_in_playwright(target_url))
+ response = "HTTP/1.1 200 OK\r\nContent-Type: application/json\r\nAccess-Control-Allow-Origin: *\r\n\r\n" + json.dumps({"status": "ok", "url": target_url})
+ writer.write(response.encode('utf-8'))
+ await writer.drain()
+ writer.close()
+ return
+ response = "HTTP/1.1 400 Bad Request\r\nContent-Type: application/json\r\nAccess-Control-Allow-Origin: *\r\n\r\n" + json.dumps({"status": "error"})
+ writer.write(response.encode('utf-8'))
+ await writer.drain()
+ except Exception:
+ pass
+ finally:
+ writer.close()
+
+ server = await asyncio.start_server(handle_client, '127.0.0.1', args.control_port)
+ print(f"Control server listening on http://127.0.0.1:{args.control_port}")
+
# Navigate after listeners attached
try:
await page.goto(args.url)
@@ -489,27 +534,31 @@ async def run_capture(args):
except Exception:
pass
- # If interactive, let user log in; otherwise start capture immediately
- if not args.no_prompt:
- print('When you have logged in in the opened browser, press Enter here to continue and capture...')
- try:
- await asyncio.get_event_loop().run_in_executor(None, input)
- except Exception:
- pass
+
print(f'Starting async passive capture (types: {args.capture_types})')
try:
if args.continuous:
- # keep running until KeyboardInterrupt
- while True:
+ # keep running until KeyboardInterrupt or browser closes
+ while not context_closed.is_set():
await asyncio.sleep(1)
+ print("Browser context closed; exiting capture script.")
else:
- await asyncio.sleep(5)
+ # wait 5s or until browser closes
+ for _ in range(5):
+ if context_closed.is_set():
+ break
+ await asyncio.sleep(1)
except KeyboardInterrupt:
print('Interrupted; closing...')
finally:
hb_task.cancel()
+ server.close()
+ try:
+ await server.wait_closed()
+ except Exception:
+ pass
try:
await context.close()
except Exception:
@@ -531,6 +580,7 @@ def parse_args():
parser.add_argument('--capture-types', default='xhr,fetch,document,other')
parser.add_argument('--dedupe-policy', default='delete', choices=['delete', 'move', 'keep', 'symlink'], help="What to do with older duplicate files: delete/move/keep/symlink")
parser.add_argument('--dry-run', action='store_true', help='If set, show dedupe actions without performing them')
+ parser.add_argument('--control-port', type=int, default=8089, help='Port for the async control server')
return parser.parse_args()
@@ -542,3 +592,6 @@ if __name__ == '__main__':
asyncio.run(run_capture(args))
except KeyboardInterrupt:
pass
+ finally:
+ import os
+ os._exit(0)
diff --git a/tools/search_md.py b/tools/search_md.py
index cff5412..b9bffbc 100644
--- a/tools/search_md.py
+++ b/tools/search_md.py
@@ -585,7 +585,8 @@ def run_search(root: str, qkey: str, qval: str, mode: str = 'exact', targets: Li
'pageKeywords': fm.get('pageKeywords'),
'reasons': sorted(list(set(reasons))),
'snippet': snippet,
- 'linked_info': check_linked_sections(content, root)
+ 'linked_info': check_linked_sections(content, root),
+ 'is_cached': True
})
if expand_links:
@@ -616,10 +617,25 @@ def run_search(root: str, qkey: str, qval: str, mode: str = 'exact', targets: Li
'pageKeywords': fm.get('pageKeywords'),
'reasons': [f'Linked (Anatomy of {parent_title})'],
'snippet': content[:300] + '...' if content else '',
- 'linked_info': check_linked_sections(content, root)
+ 'linked_info': check_linked_sections(content, root),
+ 'is_cached': True
})
- seen_docids.add(docid)
seen_paths.add(path)
+ else:
+ expanded_results.append({
+ 'path': f"missing_{docid}",
+ 'title': link['title'],
+ 'docid': docid,
+ 'breadcrumbs': [],
+ 'authors': [],
+ 'pageKeywords': [],
+ 'reasons': [f'Linked (Anatomy of {parent_title})'],
+ 'snippet': '',
+ 'linked_info': None,
+ 'is_cached': False
+ })
+ seen_paths.add(f"missing_{docid}")
+ seen_docids.add(docid)
# Differential links
for link in info['differential']['links']:
@@ -637,10 +653,25 @@ def run_search(root: str, qkey: str, qval: str, mode: str = 'exact', targets: Li
'pageKeywords': fm.get('pageKeywords'),
'reasons': [f'Linked (Diff Diag of {parent_title})'],
'snippet': content[:300] + '...' if content else '',
- 'linked_info': check_linked_sections(content, root)
+ 'linked_info': check_linked_sections(content, root),
+ 'is_cached': True
})
- seen_docids.add(docid)
seen_paths.add(path)
+ else:
+ expanded_results.append({
+ 'path': f"missing_{docid}",
+ 'title': link['title'],
+ 'docid': docid,
+ 'breadcrumbs': [],
+ 'authors': [],
+ 'pageKeywords': [],
+ 'reasons': [f'Linked (Diff Diag of {parent_title})'],
+ 'snippet': '',
+ 'linked_info': None,
+ 'is_cached': False
+ })
+ seen_paths.add(f"missing_{docid}")
+ seen_docids.add(docid)
out.extend(expanded_results)
diff --git a/tools/search_md_gui.py b/tools/search_md_gui.py
index 5048b5f..1706654 100644
--- a/tools/search_md_gui.py
+++ b/tools/search_md_gui.py
@@ -353,14 +353,24 @@ def search_page() -> None: # build UI
table.add_slot('body-cell-title', '''
''')
@@ -406,12 +416,59 @@ def search_page() -> None: # build UI
table.add_slot('body-cell-path', '''
- {{ props.row.path.split('/').pop() }}
+ {{ props.row.is_cached !== false ? props.row.path.split('/').pop() : 'N/A (Missing)' }}
''')
table.on('expand_row_links', lambda msg: asyncio.create_task(expand_row_links_handler(msg.args)))
table.on('show_links_modal', lambda msg: show_links_modal_handler(msg.args))
+ table.on('capture_article', lambda msg: asyncio.create_task(trigger_capture_handler(msg.args)))
+
+ async def trigger_capture_handler(args: dict):
+ docid = args.get('docid')
+ title = args.get('title')
+ target_url = make_online_url(docid, title)
+
+ def check_and_send():
+ import urllib.request
+ import urllib.parse
+ try:
+ url = f"http://127.0.0.1:8089/open?url=" + urllib.parse.quote(target_url)
+ with urllib.request.urlopen(url, timeout=2.0) as resp:
+ return resp.status == 200
+ except Exception:
+ return False
+
+ with table.client:
+ ui.notify(f"Checking capture browser status for: {title}...", type='info')
+ ok = await asyncio.to_thread(check_and_send)
+ if ok:
+ ui.notify(f"Requested capture browser to open: {title}", type='positive')
+ return
+
+ ui.notify("Capture browser not responding. Cleaning up existing capture processes...", type='warning')
+ try:
+ # Terminate any existing capture script processes
+ subprocess.run(['pkill', '-f', 'capture_passive_playwright_async.py'], stdout=subprocess.DEVNULL, stderr=subprocess.DEVNULL)
+ await asyncio.sleep(1.0) # brief pause for os to clean up
+
+ ui.notify("Launching fresh capture browser...", type='info')
+ subprocess.Popen([
+ 'uv', 'run', 'python', 'scrapers/capture_passive_playwright_async.py',
+ '--output-dir', 'xhr_captured_async',
+ '--continuous'
+ ], stdout=subprocess.DEVNULL, stderr=subprocess.DEVNULL)
+
+ # Wait 5 seconds for the browser context to open and port to listen
+ await asyncio.sleep(5.0)
+
+ ok_again = await asyncio.to_thread(check_and_send)
+ if ok_again:
+ ui.notify(f"Capture browser launched successfully. Opened: {title}", type='positive')
+ else:
+ ui.notify("Capture browser process launched, but command port timed out. Try clicking again in a few seconds.", type='warning')
+ except Exception as e:
+ ui.notify(f"Failed to start capture browser: {e}", type='negative')
async def expand_row_links_handler(path: str):
with table.client:
@@ -464,10 +521,32 @@ def search_page() -> None: # build UI
'pageKeywords': fm.get('pageKeywords'),
'reasons': [origins[docid]],
'snippet': content[:300] + '...' if content else '',
- 'linked_info': search_md.check_linked_sections(content, root_input.value)
+ 'linked_info': search_md.check_linked_sections(content, root_input.value),
+ 'is_cached': True
})
seen_docids.add(docid)
seen_paths.add(doc_path)
+ else:
+ fallback_title = "Linked Document"
+ for l in info['anatomy']['links'] + info['differential']['links']:
+ if l['docid'] == docid:
+ fallback_title = l['title']
+ break
+ fake_path = f"missing_{docid}"
+ res.append({
+ 'path': fake_path,
+ 'title': fallback_title,
+ 'docid': docid,
+ 'breadcrumbs': [],
+ 'authors': [],
+ 'pageKeywords': [],
+ 'reasons': [origins[docid]],
+ 'snippet': '',
+ 'linked_info': None,
+ 'is_cached': False
+ })
+ seen_docids.add(docid)
+ seen_paths.add(fake_path)
return res
new_rows = await anyio.to_thread.run_sync(fetch_linked)
@@ -515,11 +594,21 @@ def search_page() -> None: # build UI
docid = link['docid']
linked_title = link['title']
already_added = any(r.get('docid') == docid for r in table.rows if r.get('docid'))
+ cached = is_doc_cached(docid)
with ui.row().classes('w-full items-center justify-between p-2 rounded bg-slate-800 border border-slate-700 hover:border-blue-500 transition-all'):
- with ui.row().classes('items-center gap-2 flex-grow'):
- ui.icon('link', color='primary').classes('text-sm')
- ui.link(linked_title, f'/document/{docid}', new_tab=True).classes('text-blue-300 hover:text-blue-200 font-semibold text-sm')
+ if cached:
+ with ui.row().classes('items-center gap-2 flex-grow'):
+ ui.icon('link', color='primary').classes('text-sm')
+ ui.link(linked_title, f'/document/{docid}', new_tab=True).classes('text-blue-300 hover:text-blue-200 font-semibold text-sm')
+ else:
+ with ui.row().classes('items-center gap-2 flex-grow'):
+ ui.icon('link', color='warning').classes('text-sm')
+ ui.label(linked_title).classes('text-slate-400 font-semibold line-through text-sm')
+ ui.label('Not Cached').classes('text-red-400 text-xs font-semibold px-2 py-0.5 rounded bg-red-950/40 border border-red-800')
+ def make_capture_click(d_id=docid, t_title=linked_title):
+ return lambda: asyncio.create_task(trigger_capture_handler({'docid': d_id, 'title': t_title}))
+ ui.button(icon='public', on_click=make_capture_click()).classes('text-xs text-yellow-400 hover:bg-yellow-900/20').props('flat round dense')
if already_added:
ui.label('Added').classes('text-green-400 text-xs font-semibold px-2 py-1 rounded bg-green-950/40 border border-green-800')
@@ -556,9 +645,21 @@ def search_page() -> None: # build UI
'authors': fm.get('authors'),
'pageKeywords': fm.get('pageKeywords'),
'reasons': [f'Linked ({section_title} of {parent_title})'],
- 'linked_info': search_md.check_linked_sections(content, root_input.value)
+ 'linked_info': search_md.check_linked_sections(content, root_input.value),
+ 'is_cached': True
+ }
+ else:
+ return {
+ 'path': f"missing_{docid}",
+ 'title': title,
+ 'docid': docid,
+ 'breadcrumbs': [],
+ 'authors': [],
+ 'pageKeywords': [],
+ 'reasons': [f'Linked ({section_title} of {parent_title})'],
+ 'linked_info': None,
+ 'is_cached': False
}
- return None
res = await anyio.to_thread.run_sync(fetch)
if res:
@@ -593,9 +694,22 @@ def search_page() -> None: # build UI
'authors': fm.get('authors'),
'pageKeywords': fm.get('pageKeywords'),
'reasons': [f'Linked ({section_title} of {parent_title})'],
- 'linked_info': search_md.check_linked_sections(content, root_input.value)
+ 'linked_info': search_md.check_linked_sections(content, root_input.value),
+ 'is_cached': True
})
- seen_docids.add(docid)
+ else:
+ res.append({
+ 'path': f"missing_{docid}",
+ 'title': link['title'],
+ 'docid': docid,
+ 'breadcrumbs': [],
+ 'authors': [],
+ 'pageKeywords': [],
+ 'reasons': [f'Linked ({section_title} of {parent_title})'],
+ 'linked_info': None,
+ 'is_cached': False
+ })
+ seen_docids.add(docid)
return res
new_rows = await anyio.to_thread.run_sync(fetch_all)
@@ -611,113 +725,116 @@ def search_page() -> None: # build UI
ui.notify(f'Error adding documents: {e}', color='negative')
async def run_search_handler():
- has_query = False
- for q in queries:
- if q['qval'].strip():
- has_query = True
- break
- if not has_query:
- ui.notify('Please enter a search query', color='warning')
- return
-
- status.set_text('Running search...')
- search_btn.set_enabled(False)
-
- try:
- or_queries_param = []
+ with table.client:
+ has_query = False
for q in queries:
if q['qval'].strip():
- or_queries_param.append({
- 'qkey': key_select.value,
- 'qval': q['qval'],
- 'mode': q['mode'],
- 'targets': [t.lower() for t in q['targets']]
- })
-
- results = await anyio.to_thread.run_sync(
- search_md.run_search,
- root_input.value,
- 'global',
- '',
- 'exact',
- None,
- or_queries_param,
- expand_chk.value
- )
+ has_query = True
+ break
+ if not has_query:
+ ui.notify('Please enter a search query', color='warning')
+ return
+
+ status.set_text('Running search...')
+ search_btn.set_enabled(False)
- table.rows = results
- table.selected.clear()
-
- # write output if requested
- if out_input.value:
- try:
- await anyio.to_thread.run_sync(search_md.write_output, results, out_input.value, fmt_select.value)
- status.set_text(f'Found {len(results)} matches. Wrote {out_input.value}')
- except Exception as e:
- status.set_text(f'Found {len(results)} matches. Failed to write output: {e}')
- else:
- status.set_text(f'Found {len(results)} matches (not written).')
+ try:
+ or_queries_param = []
+ for q in queries:
+ if q['qval'].strip():
+ or_queries_param.append({
+ 'qkey': key_select.value,
+ 'qval': q['qval'],
+ 'mode': q['mode'],
+ 'targets': [t.lower() for t in q['targets']]
+ })
+
+ results = await anyio.to_thread.run_sync(
+ search_md.run_search,
+ root_input.value,
+ 'global',
+ '',
+ 'exact',
+ None,
+ or_queries_param,
+ expand_chk.value
+ )
- except Exception as e:
- status.set_text(f'Search failed: {e}')
- ui.notify(f'Search error: {e}', color='negative')
- finally:
- search_btn.set_enabled(True)
+ table.rows = results
+ table.selected.clear()
+
+ # write output if requested
+ if out_input.value:
+ try:
+ await anyio.to_thread.run_sync(search_md.write_output, results, out_input.value, fmt_select.value)
+ status.set_text(f'Found {len(results)} matches. Wrote {out_input.value}')
+ except Exception as e:
+ status.set_text(f'Found {len(results)} matches. Failed to write output: {e}')
+ else:
+ status.set_text(f'Found {len(results)} matches (not written).')
+
+ except Exception as e:
+ status.set_text(f'Search failed: {e}')
+ ui.notify(f'Search error: {e}', color='negative')
+ finally:
+ search_btn.set_enabled(True)
async def copy_selected():
- if not table.selected:
- ui.notify('No files selected', color='warning')
- return
+ with table.client:
+ if not table.selected:
+ ui.notify('No files selected', color='warning')
+ return
+
+ dest = copy_input.value.strip() or 'out'
+ status.set_text(f'Copying {len(table.selected)} files to {dest}...')
- dest = copy_input.value.strip() or 'out'
- status.set_text(f'Copying {len(table.selected)} files to {dest}...')
-
- try:
- os.makedirs(dest, exist_ok=True)
-
- if copy_clear.value:
- def clear_dst():
- for name in os.listdir(dest):
- path = os.path.join(dest, name)
+ try:
+ os.makedirs(dest, exist_ok=True)
+
+ if copy_clear.value:
+ def clear_dst():
+ for name in os.listdir(dest):
+ path = os.path.join(dest, name)
+ try:
+ if os.path.isfile(path) or os.path.islink(path):
+ os.remove(path)
+ elif os.path.isdir(path):
+ shutil.rmtree(path)
+ except Exception:
+ pass
+ await anyio.to_thread.run_sync(clear_dst)
+
+ def copy_files():
+ for r in table.selected:
try:
- if os.path.isfile(path) or os.path.islink(path):
- os.remove(path)
- elif os.path.isdir(path):
- shutil.rmtree(path)
+ dst = os.path.join(dest, os.path.basename(r['path']))
+ with open(r['path'], 'rb') as srcf, open(dst, 'wb') as dstf:
+ dstf.write(srcf.read())
except Exception:
pass
- await anyio.to_thread.run_sync(clear_dst)
-
- def copy_files():
- for r in table.selected:
- try:
- dst = os.path.join(dest, os.path.basename(r['path']))
- with open(r['path'], 'rb') as srcf, open(dst, 'wb') as dstf:
- dstf.write(srcf.read())
- except Exception:
- pass
- await anyio.to_thread.run_sync(copy_files)
- status.set_text(status.text + f' Copied {len(table.selected)} files to {dest}')
- ui.notify('Files copied successfully', color='positive')
- except Exception as e:
- status.set_text(status.text + f' Copy failed: {e}')
- ui.notify(f'Copy failed: {e}', color='negative')
+ await anyio.to_thread.run_sync(copy_files)
+ status.set_text(status.text + f' Copied {len(table.selected)} files to {dest}')
+ ui.notify('Files copied successfully', color='positive')
+ except Exception as e:
+ status.set_text(status.text + f' Copy failed: {e}')
+ ui.notify(f'Copy failed: {e}', color='negative')
async def export_selected():
- if not table.selected:
- ui.notify('No records selected', color='warning')
- return
+ with table.client:
+ if not table.selected:
+ ui.notify('No records selected', color='warning')
+ return
+
+ outp = out_input.value or 'results.json'
+ status.set_text(f'Exporting {len(table.selected)} records to {outp}...')
- outp = out_input.value or 'results.json'
- status.set_text(f'Exporting {len(table.selected)} records to {outp}...')
-
- try:
- await anyio.to_thread.run_sync(search_md.write_output, table.selected, outp, fmt_select.value)
- status.set_text(f'Exported {len(table.selected)} records to {outp}.')
- ui.notify('Export successful', color='positive')
- except Exception as e:
- status.set_text(f'Export failed: {e}')
- ui.notify(f'Export failed: {e}', color='negative')
+ try:
+ await anyio.to_thread.run_sync(search_md.write_output, table.selected, outp, fmt_select.value)
+ status.set_text(f'Exported {len(table.selected)} records to {outp}.')
+ ui.notify('Export successful', color='positive')
+ except Exception as e:
+ status.set_text(f'Export failed: {e}')
+ ui.notify(f'Export failed: {e}', color='negative')
def open_output_dir() -> None:
dest = copy_input.value.strip() if copy_input.value else ''
@@ -867,6 +984,18 @@ def linkify_references(content: str, root: str = 'docs_md/articles') -> str:
return content
+def is_doc_cached(docid: str) -> bool:
+ fm, _, _ = search_md.get_doc_by_id('docs_md/articles', docid)
+ return fm is not None
+
+
+def make_online_url(docid: str, title: str) -> str:
+ slug = title.lower()
+ slug = re.sub(r'[^a-z0-9]+', '-', slug).strip('-')
+ return f"https://app.statdx.com/document/{slug}/{docid}"
+
+
+
@ui.page('/document/{identifier}')
def render_doc_page(identifier: str):
ui.add_head_html('''