doi:10.1016/j.crad.2006.03.010 
Copyright © 2006 The Royal College of Radiologists Published by Elsevier Ltd.
Pictorial Review
Imaging of hepatic infections
D.J. Doyle
, a, 
, A.E. Hanbidgea and M.E. O'Malleya
aDepartment of Medical Imaging, University Health Network and Mount Sinai Hospital, University of Toronto, Toronto, Ont., Canada
Received 19 October 2005;
revised 2 March 2006;
accepted 31 March 2006.
Available online 11 August 2006.
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Imaging plays a significant role in the detection, characterization and treatment of hepatic infections. Infectious diseases of the liver include pyogenic and amoebic abscesses and parasitic, fungal, viral and granulomatous infections. With increases in worldwide travel, immunosuppression and changing population demographics, identification of cases of hepatic infection is becoming more common in daily practice. Knowledge of the imaging features seen with hepatic infections can assist in early diagnosis and timely initiation of appropriate therapy. This review presents the imaging appearances of hepatic infections, emphasizing specific features that may contribute to the diagnosis. Examples of the imaging findings seen with pyogenic and amoebic abscesses, infection with Echinococcus granulosus (Hydatid), schistosomiasis, candidiasis and tuberculosis (TB) are presented.
Figure 1. (a) Axial contrast-enhanced CT of a hepatocellular carcinoma treated with radiofrequency ablation complicated by an abscess with gas formation. Enhancement at the superolateral margin is in keeping with the residual tumour. (b) US image showing echogenic shadowing foci corresponding to the gas within the abscess. (c) Fluoroscopic image after contrast medium injection through a drainage catheter confirming the presence of an abscess cavity.
Figure 2. (a) Axial contrast-enhanced CT image showing a focal perforation at the fundus of the gallbladder with an adjacent abscess in the gallbladder fossa. Also visualized is dilalation of the common bile duct (CBD) with abnormal enhancement of the biliary epithelium. (b) Coronal CT reformation confirming obstruction of the distal CBD due to choledocholithiasis.
Figure 3. (a) Axial contrast-enhanced CT image showing an ill-defined hilar cholangiocarcinoma with biliary obstruction and external biliary drainage of the left lobe of the liver. (b) CT at a more inferior level showing an air-containing abscess secondary to malignant biliary obstruction.
Figure 4. Sagittal US image of a hypoechoic pyogenic abscess with posterior acoustic enhancement.
Figure 5. Axial contrast-enhanced CT image of a pyogenic abscess with extension through the liver capsule.
Figure 6. (a) Axial contrast-enhanced CT showing pneumobilia and two low-attenuation pyogenic abscesses with perilesional oedema. (b) Axial T1-weighted MRI showing a low signal intensity pyogenic abscess. (c) Axial T2-weighted MRI showing bright pyogenic liver abscess with perilesional oedema showing increased signal intensity. (d) T1-weighted post-gadolinium MRI showing early enhancement of the abscess wall. (e) More delayed post-gadolinium images showing persistent wall enhancement.
Figure 7. (a) US image of hypoechoic amoebic abscess with absence of significant wall echoes. (b) Corresponding axial contrast-enhanced CT demonstrating a “double target” sign of an amoebic abscess with wall enhancement and perilesional oedema.
Figure 8. (a) Sagittal US of an echogenic, “solid”-appearing amoebic abscess. (b) Corresponding axial contrast-enhanced CT demonstrating an enhancing, amoebic liver abscess with septa.
Figure 9. (a) Sagittal US image showing a small daughter cyst within a hydatid cyst. (b) Corresponding axial CT image showing similar appearances.
Figure 10. (a) Sagittal US image showing an echogenic or solid matrix with hypoechoic daughter cysts. (b) Corresponding axial contrast-enhanced CT image demonstrating daughter cysts of lower attenuation than main cyst.
Figure 11. Axial contrast-enhanced CT image showing hepatic hydatid with daughter cysts with similarly appearing peritoneal cysts due to cyst rupture and peritoneal seeding.
Figure 12. Axial contrast-enhanced CT showing linear areas of high attenuation corresponding to the “waterlily” sign of a detached endocyst.
Figure 13. Calcified hydatid on US showing posterior acoustic shadowing.
Figure 14. Sagittal US demonstrating mosaic pattern of echogenic septa or “turtle back” appearance of schistosomiasis.
Figure 15. (a) Axial contrast-enhanced CT image showing small, ring-enhancing fungal abscesses. (b) Axial T2-weighted MRI demonstrating a fungal abscess in segment 7 showing increased central T2 signal and a low signal intensity rim.
Figure 16. (a) Axial contrast-enhanced CT image showing hypoattenuating, macronodular TB nodules without significant enhancement. (b) Corresponding US image showing hypoechoic nodule.
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