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Imaging-guided parenchymal liver biopsy for diffuse liver disease is increasingly performed via an epigastric route from the left lobe, as opposed to the more traditional intercostal right-sided approach.We conducted a retrospective analysis of all liver biopsies performed at our department for 3 years (July 2007 through June 2010). A total of 1028 liver biopsies were performed during this period. Of these, 776 biopsies were performed for diffuse medical liver disease. Electronic medical records were reviewed for any documented complications.We identified six cases (0.8%) of documented significant bleeding after 776 biopsies. All bleeding complications were associated with the left-sided epigastric approach. No documented case of major bleeding from the right-sided approach was recorded during the same period. We describe four patients with severe bleeding complications in which classic imaging features were noted on CT, pointing to injury of the superior epigastric artery as the possible cause of the bleeding.It is important to recognize the subtle CT signs of superior epigastric artery bleeding because the traditional femoral approach with angiography of the hepatic and portal vessels may not reveal active bleeding. The superior epigastric artery, rather than the hepatic arteries, should be evaluated. A brachial approach for the angiogram may be the more optimal technique.

The limited availability of suitable size-matched donor whole organs has been a major cause of morbidity and mortality in infants and children requiring liver transplantation. Techniques for transplanting segments of the liver have successfully addressed this problem. The surgical anatomy of the left hepatic lobe transplant is unique in three primary respects: the cut edge, the presence of an enteric Roux loop for biliary drainage, and the alteration in the position and number of hepatic vessels. The spectrum of normal imaging findings in 17 left-lobe allografts is illustrated.

Demographic, clinical, and angiographic data were reviewed for 63 consecutive patients with hepatocellular carcinoma. Angiography remains the critical examination in determining extent of disease and potential surgical cure. Angiographic findings were correlated with surgical or autopsy findings for 26 of the patients. The absence of venous invasion and lack of involvement of at least one hepatic segment favor resectability. Selective hepatic injections and oblique views accurately answered these questions in more than 80% of our patients. Pitfalls to angiographic accuracy include vascular invasion by very small tumor masses, hypovascular or diffuse hepatocellular carcinomas, metastatic disease, and involvement of the left lobe.

Liver infarcts are relatively rare and uncommonly are diagnosed before autopsy. The CT appearance of hepatic infarction was studied in five patients. In four of these, well-defined, wedge-shaped, low-attenuation zones extending to the liver surface were seen on contrast-enhanced scans. The infarcts involved the right lobe of the liver in all patients, and the left lobe as well in two. Associated splenic infarcts were present in three patients and renal infarcts in two. While the clinical and laboratory findings in hepatic infarction can be completely mimicked by hepatic abscess, the different CT appearance of these lesions should permit noninvasive distinction in most patients.

1. One thousand liver photoscans were analyzed, 410 called normal and 203 called positive but without positive proof of accuracy. The author believes that the accuracy of photoscanning in this group is fairly high.2. A positive proof (biopsy, operation, or autopsy) of accuracy was obtained on 387 photoscans. Aspiration biopsy proved photoscanning accurate in 87 per cent, abdominal operation proved the accuracy in 71 per cent, and autopsy proved the accuracy in 72 per cent. The diagnosis was missed in 107 (27.6 per cent) of these 387 cases.3. The most common causes for false positive diagnoses were: (1) the gallbladder fossa; (2) the thinned out or small left lobe of the liver; (3) extrinsic pressure defects of tumor; (4) porta hepatis: (5) pressure defect of vertebrae; and (6) peculiar shapes of the liver.4. The most common cause for a false negative diagnosis was the inability to visualize the small (less than 3 cm.) metastasis on the photoscan. Several larger metastases of various sizes, including one 1...

Twenty-six patients with known intrahepatic dilatation were solected for color Doppler imaging (QAD I, Quantum Medical Systems, lssaquah, WA). Most patients were scanned with 5-MHz, linear-array transducers. A few patients were scanned with a 3-MHz, linear-array transducer that became available near the end of the study. Patients were selected for scanning if intrahepatic biliary dilatation had been detected by some other imaging technique, either CT (23 patients) or direct cholangiography (three patients). The size of the dilated intrahepatic ducts ranged from 2 to 10 mm. In 25 of the 26 patients, intrahepatic ductal dilatation could be detected by conventional grayscale sonography. Although an attempt was made to scan consecutive patients, it is unlikely that all patients with dilated intrahepatic ducts were scanned. No patients were excluded from color Doppler scanning for any reason. Color Doppler imaging usually was easiest to perform in the left lobe of the liver. This was related to access difficulties with the linear-array transducer and the limited depth at which color could be detected (approximately 9 cm with the 5-MHz transducer). The most superficial portions of the right lobe usually could be imaged by using the intercostal technique. The only criterion for diagnosis of intrahepatic ductal dilatation was the presence of one or more small tubular structures that did not show color-coded flow on Doppler imaging (Fig. 1). Ten patients without biliary dilatation on CT were scanned as normal control subjects. Examiners performing color Doppler sonography had preliminary knowledge ofthe presence or absence of intrahepatic biliary dilatation in the subjects studied.