RADIOLOGIC REPORTING FOR LIVER CT

CT ABDOMEN/Liver WITHOUT AND WITH CONTRAST [CT PELVIS WITH CONTRAST] LIVER SURVEILLANCE PROTOCOL {Used for workup and surveillance of known or suspected cirrhosis and focal lesions.} CLINICAL INDICATION: [Hepatitis C| Cirrhosis| End-Stage Liver Disease| Hepatic steatosis], [assess for cirrhosis and/or liver masses.] [<Free text>] COMPARISON: [<date> | None*]. TECHNIQUE: {Institution specific, with verbiage regarding post-processing per institution protocol as necessary for billing and coding purposes.} Unenhanced and multi-phasic contrast enhanced imaging of the abdomen [and pelvis]. Scan phases: [] {Post-processing description} IV contrast: [# ml] [<Contrast agent and concentration>] Oral contrast: [None |water|<other>] CT radiation dose: {Dose CTDLP: xxx mGy*cm, for example.} OBSERVATIONS: CT imaging features of cirrhosis: [Present*|Absent] Liver morphology: {if a particular attribute is present, insert a modifier phrase to assign a severity index: [Mild| Moderate| Severe]} Liver capsule: [Micronodular| Macronodular| Smooth] {free text detail} Nodular regeneration: [Present*| Absent.] {free text detail} Fibrosis: [Present*| Absent.] {free text detail} Lobar/segmental atrophy: [Present*| Absent.] {free text detail} Features of portal hypertension:

Spleen: [# cm] [AP| maximum axial| maximum coronal] dimension Portal vein diameter: [# mm] SMV or Splenic vein enlargement: [Present*|Absent] {A sensitive cutoff for portal vein is 13 mm, 10 mm for SMV and splenic vein} Ascites: [None* | Small volume| Moderate volume | Large volume | Massive volume] {free text detail} Collateral vasculature, varices: [None*| gastric varices; esophageal varices; recanalized paraumbilical vein] {free text detail} Spontaneous shunt(s): [Absent*| Present] {free text detail} Other (iatrogenic/therapeutic) shunt(s): [Not present*| Present] {free text detail} Related findings: [None* |Adenopathy] {free text detail} Liver masses: [Present*|Absent] {repeat following module for as many lesions necessary} Lesion Number: [1*|<other #>] {by convention, initial exam masses numbered largest to smallest, then based upon numbering from prior exams} Size: [# cm] [No comparison* |Compared to [# cm]] Location: Liver segment {describe consider using Couinard segments if understood by report consumers} Enhancement pattern: Arterial phase (hypervascular): [Present*| Absent.] {free text detail} Portal phase enhancement (relative to liver): [Hypoattenuating*| Isoattenuating| Hyperattenuating]. [Heterogeneous* | Homogeneous] Delayed phase enhancement (relative to liver):[Not applicable | at <time> minutes post injection:] [Hypoattenuating*| Isoattenuating| Hyperattenuating].

Lesion de-enhancement: [Present*| Absent.] {free text detail} Encapsulated appearance: [Present*| Absent.] {free text detail} Gross fat attenuation: [Present*| Absent.] {free text detail} Calcification: [Absent*| Present] {free text detail} Vascular involvement: [Absent*| Present] {free text detail} Other features: [Absent*| Present] {free text detail} Gallbladder and biliary system: [Normal| Unremarkable]. [No CT evident gallstones*|Cholelithiasis present.| Surgically absent.] Pancreas: [Normal| Unremarkable]. Kidneys and urinary tract: [Normal| Unremarkable]. [No calculi]. [No solid renal mass or cystic lesions*|One or more simple cysts, in the [right| left| right & left] kidney(s)]. Adrenal glands: [Normal| Unremarkable]. GI tract: [Normal| Unremarkable]. Peritoneum/retroperitoneum: [Normal| Unremarkable]. [No ascites]. [No adenopathy]. {Omit pelvic section reading if CT protocol excluded pelvis} Pelvic structures: [Normal*| Unremarkable.] [No pelvic lymphadenopathy.] Bladder: [Normal*| Unremarkable.] {gender specific description} Uterus & Adnexa: [Norma*l| Unremarkable.] Uterus is [present*|absent]. {free text adnexal comment} Prostate & Seminal vesicles: [Normal*|Unremarkable] Body wall and musculoskeletal: [Normal*| Unremarkable].

Visualized lower thorax: [Normal*| Unremarkable]. [No pulmonary parenchymal mass or pleural effusion.] IMPRESSION: 1. Cirrhotic changes of the liver [are*| are not] present.

2. There [is no*| is] CT evidence of hepatocellular carcinoma. There are [#] focal liver lesions. [#; all] are [definitely HCC; probably HCC; indeterminate; probably benign; benign]. LIRADS category for each lesion. {If applicable consider statement describing temporal appearance of disease such as [no change from previous study*| disease is worsening| disease is improved]

3. Evidence of portal hypertension [Unchanged, as detailed| Not present| Worsening]. [<detail>]

4. Evidence of extrahepatic spread of HCC: [Yes/No]; {If Yes:} [ ] {Comments:} [ ] 5. Recommendations: [ ]