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Figure 11. Bile leak after endoscopic cholecystectomy. A 73 year old man suffered increasing pain two days after endoscopic cholecystectomy. The immediate image (a) shows normal liver activity. Retention of radiotracer is seen in the biliary tree at 30 minutes (b). A defect in the distal CBD (arrow) is a retained calculus. Bile extravasation surrounding a biloma in the gallbladder fossa (arrowheads) is seen at 60 minutes (c).

Figure 11. Bile leak after endoscopic cholecystectomy. A 73 year old man suffered increasing pain two days after endoscopic cholecystectomy. The immediate image (a) shows normal liver activity. Retention of radiotracer is seen in the biliary tree at 30 minutes (b). A defect in the distal CBD (arrow) is a retained calculus. Bile extravasation surrounding a biloma in the gallbladder fossa (arrowheads) is seen at 60 minutes (c).

99mTc-IDA is a marker for hepatocytes. Masses containing hepatocytes such as FNH, adenoma or hepatoma do not contain bile ducts connected to the biliary tree. Images performed shortly after injection may or may not demonstrate the mass. If visible, it may appear more or less intense than normal liver depending on the relative uptake. As normal liver excretes the tracer, the masses become relatively more intense than normal liver. The technique is most useful in localizing the masses on delayed SPECT images as the precise location may be difficult to determine from US examinations where images can be obtained in any orientation. Unfortunately, benign and malignant masses cannot be separated with complete confidence as well-differentiated hepatomas will also accumulate 99mTc-IDA.

Cavernous Hemangioma

Cavernous hemagiomas are single or multiple well-circumscribed clusters of large blood filled sinuses (Figs. 12 and 13). They occur predominantly in women. Most are asymptomatic and are discovered as incidental findings during CT, MRI or ultrasound performed for other reasons. Rarely pain may result from hemorrhage or thrombosis.

On US most cavernous hemagiomas are well-defined and hyperechoic because of reflections from multiple internal septa and vessel walls. Mixed echogenicity can result from thrombosis, hemorrhage, necrosis and scarring. Findings are nonspecific and hemangiomas cannot be confidently distinguished from vascular metastases, FNH, adenoma, or hepatoma.

On CT hemangiomas are hypodense without contrast enhancement. After contrast injection there is initial peripheral or globular enhancement ("puddling") which progresses toward the center. Small lesions may enhance rapidly and may be indistinguishable from other vascular masses. Large hemangiomas may not enhance completely or fill only later when most of the contrast is in the extracellular fluid space.

On MRI most hemangiomas are well defined and hyperintense on T-2 weighted images. Large lesions and those with hemorrhage, thrombosis or scarring tend to

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