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CLINICAL ASPECT OF

ABDOMINAL DYNAMIC CT
ELYSANTI DWI MARTADIANI
UDAYANA MEDICAL FACULTY / SANGLAH GENERAL
HOSPITAL

OVERVIEW
Goal of Contrast Administration
Multiphase Abdominal CT
Contrast Dose and Injection Rate
Oral contrast
Hepatic Dynamic CT
Take Home Points

GOAL OF CONTRAST ADMINISTRATION IN CT


(CONTRAST- ENHANCED CT)
To find pathology by enhancing the contrast between a
lesion and the normal surrounding structures
A lesion could be hypovascular or hypervascular
compared to the normal tissue in a certain phase of
enhancement
Important : to know in which phase a CT should be
performed depending on the pathology that you are
looking for

Abdominal Single slice CT Era

PRE CONTRAST

POST CONTRAST

ABDOMINAL
DYNAMIC CT

OVERVIEW
Goal of Contrast Administration
Multiphase Abdominal CT
Contrast Dose and Injection Rate
Oral contrast
Hepatic Dynamic CT
Take Home Points

Multiphase in abdominal CT
Non-enhanced CT (NECT) / Plain CT
Contrast enhanced CT (CECT)
Early arterial phase
Late arterial phase ( early venous portal phase)
Hepatic ( late portal phase )
Nephrogenic phase
Delayed phase ( wash out phase / equilibrium phase)

NON- ENHANCED CT (NECT) / PLAIN CT


Helpful in detecting :
Calcifications
Stones
Fat in tumors
Fat-stranding
( in inflammation
:
appendicitis,
omental

Early arterial phase / early venous


portal phase

Approx. 15-20 second


post injection or
immediately after
bolus tracking
Contrast is still in the
arteries
Contrast has not
enhanced the organs
and other soft tissues
Time window is limited

Late arterial phase / arterial phase /


early venous portal phase
Approx. 35-40 second
post injection or 15-20
sec after bolus tracking
Some enhancement of
the portal vein can be
seen
All structures that get
their blood supply from
the arteries will show
optimal enhancement

http://www.radiologyassistant.nl/en/p52c04470dbd5c
/ct-contrast-injection-and-protocols.html

Hepatic / late portal venous


phase
Approx. 70-80 sec post injection
or 50-60 sec after bolus tracking
The liver parenchyma enhances
through blood supply by the
portal vein
Some enhancement of the
hepatic veins.
Liver should be loaded by
contrast need time for
contrast to get from the portal
vein into the liver parenchyma.
Do not be too early

http://posterng.netkey.at/esr/viewing/index.php?module=viewin
g_poster&task=viewsection&pi=117&ti=7230&searchkey
=

Hepatic /
late portal venous phase

Important to evaluate :
Portosystemic
collateral in

http://posterng.netkey.at/esr/viewing/index.php?module=viewimage&task
=&mediafile_id=533120&201312301609.gif

liver chirrosis
Thrombus inside of
the portal venous
http://eurorad.org/eurorad/view_figure.php?pubid=9807&figid=
29153&nr=1

Nephrogenic phase
Approx. 100 second
post injection or 80 sec
after bolus tracking
All of the renal
parenchyma including
the medulla enhances.
Enable to detect small
renal cell carcinomas.
Sanchez et al. ECR 2010 / C-1342 MDCT and MR in the diagnosis,
characterization and staging of renal cell carcinoma. Radiologicpathologic correlation. http://
posterng.netkey.at/esr/viewing/index.php?module=viewing_po
ster&task=viewsection&pi=101337&ti=304222&searchkey

Delayed phase / wash out phase / equilibrium phase


Approx. 6-10 minutes post
injection or 6-10 minutes
after bolus tracking
Wash out of contrast in all
abdominal structures except
for fibrotic tissue
Fibrotic tissue has a poor late
wash out will become
relatively dense compared to

RECALL : WHAT KIND OF PHASE


ARE THESE PICTURES ?

DYNAMIC CT OF THE KIDNEY


Great controversy with protocols varying between
institutions
100-120 cc of non-ionic contrast
Using a power injector
Approximately 20 seconds post injection for arterial phase
Approximately 30-45 seconds post injection for the cortico
medullary phase
Approximately 1-4 minutes post injection for the
nephrographic phase
Approximately starts from 3- 4 minutes p.i.
http://pubs.rsna.org/doi/pdf/10.1148/radiographics.15.5.7501851

MULTIPHASE IN KIDNEY CT
Non enhanced CT look for the stone
Phases of enhancement :
Cortical angiogram
occur within a few second, not routinely
Glomerulogram
Cortical nephrogram : corticomedullary
differentiation
Tubular nephrogram / nephrographic phase
Delayed / excretory phase

Non contrast

Corticomedull
ary phase

Nephrogenic
phase

Delayed
phase

Sanchez et al. ECR 2010 / C-1342 MDCT and MR in the diagnosis, characterization and staging of renal cell carcinoma.
Radiologic-pathologic correlation.
http://posterng.netkey.at/esr/viewing/index.php?module=viewing_poster&task=viewsection&pi=101337&ti=304222&sea

RECALL : WHAT KIND OF PHASE


ARE THESE PICTURES ?

OVERVIEW
Goal of Contrast Administration
Multiphase Abdominal CT
Contrast Dose and Injection Rate
Oral contrast
Hepatic Dynamic CT
Take Home Points

CONTRAST DOSE FOR DYNAMIC


CT
Weight < 75kg : 100cc
Weight 75-90kg: 120cc
Weight > 90kg : 150cc
http://www.radiologyassistant.nl/en/p52c04470dbd5c/ct-contrast-injection-and-protocols.h
tml

Injection Rate of Contrast Agent

18 gauge i.v
catheter 5 cc /
sec
For all indication
Especially for GIbleeding,
liver tumor
characterisation,
pancreatic carcinoma
Hold the arm stretched

20 gauge pink
venflon 3-4
cc / sec
Indication :
- If 5cc/sec is not
possible
- Only interested in
the
late portal phase

http://www.radiologyassistant.nl/en/p52c04470dbd5c/ct-contrast-injection-andprotocols.html

OVERVIEW
Goal of Contrast Administration
Multiphase Abdominal CT
Contrast Dose and Injection Rate
Oral contrast
Hepatic Dynamic CT
Take Home Points

ORAL CONTRAST
POSITIVE ORAL CONTRAST
Has some disadvantages
Usually only a portion of
the bowel is filled with
contrast
More radiation is needed
in areas of positive
contrast to get the same
quality of images
Enhancement of the bowel
wall is obscured

LOW SUSPENSION
BARIUM
NEGATIVE ORAL CONTRAST

Fat containing milk

Water

Advantage :
Enhancement of the bowel wall is not
obscure

Positive oral
contrast

http://www.ijri.org/viewimage.asp?img=In
dianJRadiolImaging_2013_23_4_373_125594_
u1.jpg

http://www.med.harvard.edu/JPNM/TF99_00/Mar7/CTsple
en.gif

Negative oral
contrast

http://www.ijri.org/viewimage.asp?img=IndianJRa
diolImaging_2013_23_4_373_125594_u1.jpg

http://pubs.rsna.org/doi/full/10.1148/rad
iology.211.3.r99jn25870

OVERVIEW
Goal of Contrast Administration
Multiphase Abdominal CT
Contrast Dose and Injection Rate
Oral contrast
Hepatic Dynamic CT
Take Home Points

HEPATIC DYNAMIC CT

LIVER
Dual blood supply : 80% by the portal vein
20% by the hepatic artery
On a non enhanced CT-scan (NECT) liver tumors
are not visible, because the contrast between
tumor tissue and the surrounding liver
parenchyma is too low.

LIVER
Minimal parenchymal enhancement in the
late arterial phase at 35-40 second post
injection
Parenchyma will enhance maximally in the
hepatic phase / late portal phase ( at 70-80
second post injection)

Hypervascular and hypovascular liver tumor


All liver tumors get 100% of their
blood supply from the hepatic artery
A hypervascular tumor best seen
in the late arterial phase
A hypovascular tumor minimal
enhancement in the late arterial
phase
Best seen when the surrounding
tissue enhances, i.e. in the late
portal (or hepatic) phase at 75-80
sec p.i.

Liver tumor characteristic based on its


enhancement
Hypervascular lesion
in late arterial
phase :
Hepatocellular
carcinoma / HCC
Focal nodular
hyperplasia (FNH)
Liver Adenoma

Hypovascular
lesions in late
venous portal /
hepatic phase :

Lesion which hold


contrast longer /
Fibrotic lesions :
Cholangiocarcinoma
Fibrotic metastases

Metastase

Lesion with delayed


enhancement
Hemangioma

Cysts
Abscess
http://www.radiologyassistant.nl/en/p446f010d8f420/liver-masses-icharacterization.html

http://www.radiologyassistant.nl/en/p446f010d8f420/liver-masses-icharacterization.html

Hypervascular liver
tumor

Arterial phase :
hypervascular
FNH

Portal venous
phase:
hypovascular
metastasis

Equilibrium phase :
dense
cholangiocarcinoma

http://www.radiologyassistant.nl/en/p446f010d8f420/liver-masses-icharacterization.html

LIVER
HEMANGIO
MA

http://www.scielo.br/scielo.php?pid=s0100-39842006000300013&script=sci_a
rttext&tlng=en

TAKE HOME POINTS


Dynamic Abdominal CT : better visualization of
patologic lesion
Hepatic dynamic CT : non contrast, arterial phase ,
portal venous phase, equilibrium phase
Kidney dynamic CT : non contrast, arterial phase,
cortico-medullary phase, nephrographic phase,
delayed / excretory phase
Liver mass : hypervascular and hypovascular
Important to know about clinical aspect to get
appropriate abdominal CT

THANK YOU