Symposium on Radiology in Internal Medicine

Hepatomegaly Juri V. Kaude, M.D.,* and Frank DeLand, M.D.**

Hepatomegaly may be caused by a primary liver disease, or the liver may become involved secondary to a disease process elsewhere in the body. In either case the clinical examination and the results of laboratory tests will indicate the type of radiologic investigations to be performed. A simplified example of the importance of the clinical diagnosis would be the enlarged liver in a patient with heart failure. It is obvious that in this case a chest roentgenogram would reveal more diagnostic information than a comparable study of the abdomen that is obtained to determine the liver size. Laboratory tests are frequently helpful in the correct choice of radiologic examination technique. For example, the time for the infusion of contrast medium in intravenous cholangiography will vary, depending on the status of the liver function tests, particularly the serum level of bilirubin. If renal function is impaired cholangiography should not be performed because of increased risk of complications in those patients with hepatorenal syndrome. Furthermore, when a radiologic procedure requires the intravascular use of contrast media, history of allergy, particularly from a previous examination, must be obtained. Although the radiologist should question the patient carefully before administration of contrast medium, any additional information from the clinician on previous allergies is useful. Thus, the radiologic investigation of hepatomegaly begins in the clinic and the success of the investigation-as in every other radiologic examination-depends on cooperative effort between the clinician and the radiologist. This cooperation will yield maximum diagnostic information for the individual patient, and will avoid unnecessary procedures that involve risk to the patient and unnecessary expenditures of time and money. We can classify radiologic procedures for the investigation of hepatomegaly as "direct and indirect" examinations. In "direct" examinations, anatomic morphology of the liver, the vasculature, and the biliary system are the targets of the procedure, whereas in "indirect" examina':'Professor of Radiology, University of Florida College of Medicine; Chief of Gastrointestinal and Genitourinary Tract Radiology, University of Florida Teaching Hospital; Consultant in Radiology, Veterans Administration Hospital, Gainesville, Florida **Professor of Radiation Medicine, University of Kentucky; Chief of Nuclear Medicine, A. B. Chandler Medical Center, Lexington, Kentucky

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tions, those changes found in other organs may suggest the possibility of liver pathology. For example, varices detected at barium examination of the esophagus (Fig. 1) suggest collateral venous flow in the presence of portal hypertension, but the reasons for the condition must still be determined. Collateral venous channels may be secondary to hepatic cirrhosis; portal vein obstruction by neoplasm or superior vena cava obstruction without concomitant portal hypertension. The radiologic procedures in the investigation of hepatomegaly include studies without and with contrast media, radionuclide investigations, and ultrasonic scanning of the liver (Table 1).

Plain Roentgenograms The size of the liver can be estimated from plain roentgenograms. Quantitative evaluation of liver volume68 is not used frequently because measurements determined by means of radionuclide or ultrasonic scanning18 , 50, 56 are more precise and provide additional information about the liver and the spleen. Opacities found on plain roentgenograms may be gall stones, intrahepatic calcifications in granulomas, hemangiomas, primary and metastatic neoplasms,6, 8, 30, 45 hydatid cystS,t2 and in inflammatory conditions such as abscesses or syphilitic gummata. 30 Occasionally thorium dioxide (Thorotrast) deposits are found in the liver (and the spleen) many years after cerebral angiography or intravenous administration. The presence of thorium dioxide should alert the examiner to the possibility of hepatic cir-

Figure 1. Esophageal varices in a patient with hepatic cirrhosis, shown bya 70mm fluorogram from the output screen of an image intensifier. Esophotrast was used to coat the esophageal mucosa.

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Table 1. Radiologic Procedures in Investigation of Hepatomegaly Studies without Contrast Media Plain films of the abdomen, liver and gall bladder region Tomography or zonography (cut films) Chest x-ray with or without fluoroscopy Barium Studies Esophagus Stomach and duodenum Small bowel Colon Contrast Studies of the Biliary System Oral cholecystography Intravenous cholangiography Transduodenal pancreato-cholangiography Percutaneous transhepatic cholangiography Operative and postoperative (T-tube) cholangiography Vascular Studies Arteriography Venography Portography (splenoportography; percutaneous, transhepatic; transumbilical portography) Radionuclide Imaging Intravenous administration 1. Anatomical studies 2. Functional studies (biliary system) Catheter administration 1. Arterial 2. Venous Ultrasonic Scanning (B-mode)

rhosis and malignant tumors as late effects of this radioactive pharmaceutical. 5 • 39 Intrahepatic gas may be observed in abscesses, in the biliary tree following surgery (Fig. 2), in cholangitis with gas-producing microorganisms, or perforation of the gall bladder into the bowel; and in the portal veins secondary to gangrene of the bowel,31 Plain roentgenograms of the abdomen frequently offer valuable diagnostic information or indicate what further diagnostic procedures should be pursued. Unfortunately this study is often treated in a desultory manner without adequate technique or interpretation. Barium Studies In hepatomegaly, the examination of the alimentary tract is usually performed in the search for a primary tumor, or to determine the presence of esophageal or gastric varices. The referring physician should indicate that the patient may have varices since the detection of small varices requires special examination techniques and the demonstration of varices is frequently improved by the use of spasmolytic agents. 49

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Figure 2. Gas (and barium) in the intrahepatic bile ducts (plain arrow) in a patient who had undergone choledochoduodenostomy because of pancreatitis and pancreatic carcinoma. The duodenum is invaded and the antrum of the stomach is elevated by the mass in the head of the pancreas (tailed arrows).

Hepatomegaly, or an abdominal mass or tumor may cause displacement of the stomach or the bowel (Fig. 3A). Since this differential diagnosis can be difficult by clinical evaluation and by barium study, a liver scan is usually helpful in defining the size and position of the liver. Angiography is the method of choice to determine the origin and nature of the mass (Fig. 3B). Hypotonic duodenography43 has gained wide popularity in investigation of duodenal and pancreatic disease21 with or without obstructive jaundice, and with or without hepatomegaly. The method may add diagnostic information in certain cases but its practical value has been recently (and correctly) questioned by Svart,64 as he states that good quality compression spot films made under fiuoroscopic control are as informative as hypotonic duodenography. Contrast Studies of the Biliary System In jaundiced patients and in patients with abnormal liver functions oral cholecystography has little or no diagnostic value. The examination of the biliary tract and the gall bladder can still be performed by means of intravenous cholangiography. Prolonged infusion of the contrast medium (20 gm of substance over 12 hours)22, 32, 48 may be diagnostic in patients with moderately severe obstructive jaundice or parenchymatous liver disease (Fig. 4A). Intravenous cholangiography should be performed always with lJody section tomography. Special procedures for examination of the bile ducts include transduodenal pancreatocholangiography47,61 and percutaneous transhepatic

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Figure 3. Patient with undifferentiated carcinoma of the left lung and hepatomegaly. A, Upper gastrointestinal examination shows displacement of the stomach by the enlarged liver. B, Hepatic arteriogram shows multiple, irregular, richly vascularized metastatic nodules with necrotic areas in the enlarged liver. This appearance is characteristic of hemangioendothelial tumor or (in a woman) metastatic choriocarcinoma. With the patient's history it must be assumed that the metastatic lesions are from the (previously removed) carcinoma of the lung.

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A Figure 4. A, Intravenous cholangiogram (cut film) in a patient with obstructive jaundice (serum bilirubin 6.4 mg. per 100 ml). Faint opacification of a dilated common bile duct (outlined) was produced by 40 cc of Cholografin in 500 cc of saline infused, over 12 hours. The distal part of the duct is stenotic (arrow). The study was diagnostic and the patient was spared a transhepatic cholangiogram. B, Operative cholangiogram for comparison (benign stricture).

cholangiography59,69 (Figs. 5 and 8B). Since the procedures entail injection of contrast medium directly into bile ducts, the exact site and in most cases the cause of the obstruction will be demonstrated. Percutaneous cholangiography is usually performed just prior to surgery. The catheter may be left in place for palliative temporary decompression of the bile ducts when surgery is contraindicated. 36 Intrahepatic biopsy and therapeutic dilatation of stenotic lesions of the common bile duct can be performed58 via transjugular catheterization of the bile ductsP With the transjugular approach possible complications from the puncture of the liver capsule (intra-abdominal bleeding or bile peritonitis) are unlikely to occur. But since this procedure is more time consuming, requires special instrumentation, and entails a higher risk of septicemia, the transjugular procedure should be limited to selected cases only. If operative cholangiography is performed routinely, it will reduce the incidence of overlooked common bile or hepatic duct stones and the number of re-operations. 29 , 46 Vascular Studies In the 1950's methods were developed to examine all three vascular systems of the liver: the hepatic arteries3 and veins66 by selective catheterization, and the portal vein by intrasplenic injection of contrast medium,n,41 by direct percutaneous puncture,4 and by transumbilical catheterization. 26 Percutaneous catheterization technique 59 for selective

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Figure 5. Percutaneous transhepatic cholangiogram in a patient with obstructive jaundice. The enlarged liver is punctured in the midaxillary line and exhibits grossly dilated bile ducts. The obstruction (arrow) was caused by a pancreatic carcinoma.

Figure 6. Selective hepatic arteriography (axillary approach). Well vascularized hepatocellular carcinoma in the right lobe of the liver (arrows).

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visceral angiography46a and the development of less toxic contrast media have made these angiographic techniques applicable for routine use. ARTERIOGRAPHY. Of the vascular studies, hepatic arteriography has the greatest specincity for investigation of hepatic tumors and mass lesions. The site for catheter placement-i.e., celiac, hepatic, splenic, or superior mesenteric arteries-depends on the vascular anatomy of the liver, the type of diagnostic information desired and any arterial changes that make selective catheterization difficult, but (in experienced hands) seldom impossible. Since the blood supply to tumors is arterial,!3, 28 neoplastic vascularity is best demonstrated by arterial injection. Of the primary hepatic neoplasms, hepatocellular carcinomas are usually highly vascularized6, 35, 38, 53,62 and frequently obstruct the portal vein (Fig. 11), Cholangiocarcinomas are less usually vascularized and may be recognized by vessel displacement, encasement or occlusion.6, 35, 38, 62 Focal hepatic lymphomas present as hypo vascularized lesions that displace vessels. 16 Small metastatic lesions are usually well vascularized and although they may become necrotic with enlargement, these tumors retain a well vascularized peripheral rim.34, 37, 70 From the angiographic appearance of the metastatic lesions, origin of the primary tumor can be suggested in certain cases. Angiographic findings characteristic for some hepatic neoplasms are shown in Figures 3B, 6, 7A, SA, and 9. Benign hepatic tumors rarely cause clinical symptoms but may enlarge and become palpable. Hemangiomas are highly vascularized and demonstrate very slow blood flow, although arteriovenous shunting in them may be present. 53 Adenomas and nodular hyperplasia are also highly vascularized. 25 Dilated vascular malformations are typical findings in hamartomas. 33 ,53 Hepatic arteriography is successful in defining other hepatic· masses, such as hydatid cysts,24,55 abscess62 (Fig. 10), hematomas, and other traumatic lesions.7 In some cases, tumor definition can be improved by pharmacoangiography, i.e., intra-arterial injection of pharmaceutical agents such as epinephrine2, 37 just prior to the injection of contrast medium. In hepatic arteriography, the slow injection of large quantities of contrast medium will demonstrate well vascularized tumors in the order of 2 mm. 34,70 In many instances hepatic arteriography is more reliable than liver biopsy obtained either by the percutaneous route or directly at the time of surgery,35 Arteriography is an essential prerequisite for hepatic surgery or palliative treatment of hepatic neoplasms by the intra-arterial infusion of cytotoxic agents,71

Portography The examination of the portal venous system by percutaneous puncture of the spleen (splenoportography, Fig, 11), by catheterization of the portal vein via the ligamentum teres,!5 or by percutaneous transhepatic puncture is now less frequently performed, Currently selective splenic arteriography or intra-arterial injection of vasodilators preceding superior mesenteric artery study offer excellent visualization of the portal (Text continued on page 157,)

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Figure 7. Hepatocellular carcinoma in the right lobe of the liver. A, The tumor contains numerous neoplastic vessels, and it was thought that some of these originated from the overlycing cystic artery (arrows). B, The scan shows that the tumor is entirely intrahepatic (arrows).

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Figure S. Primary cholangiocarcinoma. A, Angiography of the celiac axis shows some small neoplastic vessels in the medial part of the right liver lobe (plain arrow). Several branches of the left hepatic artery are irregular and encased by the tumor (tailed arrow). (The right hepatic artery originates from the superior mesenteric artery.) B, Transhepatic cholangiogram demonstrates the site of the obstruction (arrow), which is in the area of the liver hilum where tumor vascularity was demonstrated by angiogram.

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Figure 9. Hepatic metastases from a poorly differentiated adenocarcinoma. The small tumor nodules are well vascularized (plain arrow). The larger lesions are necrotic, but there is still a hypervascular peripheral rim present (tailed arrows).

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Figure 10. Amebic abscess in the liver. A, Hepatic arteries are displaced by the avascular mass (arrows). B, During the venous phase an irregular hypervascular zone outlines the abscess (arrows). C, Liver scan one month later (after 10 days' treatment with metronidazole) still shows the abscess.

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Figure 11. Splenoportography in a patient admitted because of bleeding from esophageal varices thought to be secondary to hepatic cirrhosis. The portal vein, however, is obstructed (arrow) by a tumor (hepatocellular carcinoma). Numerous venous collateral channels are present.

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Figure 12. Arterial portogram by splenic artery injection in a patient with hepatosplenomegaly, liver cirrhosis and portal hypertension. Good demonstration of the splenic and portal veins (plain arrows) and the collateral venous channels (tailed arrows) make a splenoportogram unnecessary.

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system in most cases14 (Fig. 12). The vasodilators most frequently used for that purpose are bradykinin9 and tolazoline,52 which increase blood flow, promoting accumulation of contrast medium during the venous phase. In splenoportography with oily contrast medium, intrahepatic masses as small as 1 cm in size are demonstrable. 40. 42 The method still offers less specificity and definition than selective hepatic arteriography for the detection of tumors, and carries more inherent risks (such as intra-abdominal bleeding) than arteriography.

Hepatic Venography Since the size of tumors that can be demonstrated by selective hepatic venography is of the order of 2 cm,54 this procedure is not satisfactory for the detection of smaller hepatic masses. However valuable information such as wedge pressure measurements and demonstration of retrograde blood flow portal hypertension can be obtained from hepatic venous catheterization.67 Hepatic venography remains also the method of choice to verify or exclude hepatic venous obstruction (Fig. 13B). Radionucli.de Imaging Visualization of the liver by means of radionuclide imaging is based on either of two physiologic processes: (1) phagocytosis of appropriate sized particles by the Kupffer cells that line the liver sinusoids and form a component of the reticuloendothelial system, or (2) the extraction from blood by means of the hepatic polygonal cells and excretion into the biliary system. Under many pathologic. circumstances, imaging of the liver by. either of these two physiological processes will reflect the functional status of the liver. Static radionuclide images of the liver performed with a radiopharmaceutical handled by either the Kupffer cells or the polygonal cells will usually reflect similar changes, since in most instances there is a direct correlation between the functional status of the two types of cells within the liver, Le., when there is decreased function in one type of cell there is usually a concomitant decrease in the other.57 One of the first agents used for liver scanning was rose bengal labeled with radioactive iodine-131, which is extracted by the polygonal cells of the liver and excreted into the biliary tract.65 Although 1311-rose bengal is satisfactory for evaluating liver function, the absorbed radiation associated with 131 1 limits the amount that can be given for a hepatic study (usually 150 ~Ci for an adult). With this level of gamma emission the number of photons per unit available for imaging is suboptimal for high resolution studies. The introduction of 198 Au colloid for hepatic scanning provided improved radionuclide images of the liver.63 Although the amount of radioactivity used for both 198Au colloid and 1311-rose bengal is the same, nearly all the colloid is immediately concentrated in the liver and the number of photons per unit area is greater with the colloid. The development of technetium-99m-sulfur-colloid was a major advance in improving the information content of radionuclide images because the radiation characteristics of 99mTc made it possible to use much larger doses of Technetium-99m from 2 to 6 millicuries. The lower gamma energy (140 keV) makes it possible to utilize stationary imaging devices with large crystals much more effectively.

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Newerradiopharmaceuticals have been developed which are hepatic cell agents but can be given in millicurie quantities and offer both physiologic information and anatomic images. Dihydrothiotic acid labeled with 99mTc and rose bengallabeled with 1231 are examples of newer drugs which offer both capabilities and will probably be available in the very near future. Radiopharmaceuticals such as gallium-67 or indium-l11 frequently help in the differential diagnosis of hepatic mass lesions, since they show some preferential accumulation in certain neoplasms, melanomas, and bronchogenic carcinomas (Fig. 16B). An image can be obtained within a few minutes after the intravenous injection of one of the colloid radiopharmaceuticals. If the radiopharmaceutical is handled by the polygonal cells, then liver images are usually obtained at several time intervals following the intravenous injection of a material such as 131 I-rose bengal. Routinely, examinations are obtained at 30 minutes, 1 hour, and 3 hours after injection, however these examination times will vary with the clinical situation. In order to obtain as much information as possible multiple images from different projections are obtained. Anterior, posterior, and both lateral views should routinely be performed with rectilinear instruments, and additional oblique views should be acquired when a fixed imaging device such as one of the large crystal cameras is used. 20 Whether a moving type instrument such as a rectilinear scanner or a fixed imaging device is employed, radionuclide images of the spleen must also be included in every examination of the liver since the spleen frequently offers indirect evidence in the differential diagnosis of hepatic pathology. The resolution of hepatic images with either moving rectilinear or a large crystal camera type equipment is in the order of about two to three cm. Smaller mass lesions can usually not be identified. The reason for limitation of resolution particularly in the right lobe are: (1) constant movement of the liver from respiratory motion during the entire examination, and (2) technical difficulties attributed to the detection of a "cold" area of radioactivity in a sea of "hot" activity. Although these two problems beset nearly all departments of nuclear medicine, fortunately significant advances are now in progress for their correction. Electronic triggering mechanisms are available for eliminating hepatic motion by means of collecting data during a specific portion of the respiratory cycle such as during the static period at the end of expiration. The problems involved in the detection of a "cold" area in a "hot" area of radioactivity relate to limitation in the design of the instrumentation. It is not appropriate at this time to discuss the specificities of this problem except to note that encouraging advances are being made to minimize instrumental deficiencies by means of routine computer correction techniques. In the differential diagnosis of hepatomegaly it is first necessary to determine if the liver is enlarged. Rollo and DeLand56 have developed a method for determining liver mass from the full size anterior and right lateral views. Their method is based on resolving the liver into two geometric portions, the right lobe as an ellipsoid and the left lobe as a paraboloid. Liver mass varies as a function of body surface area which is determined from the patient's height and weight. 18 The calculated liver

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mass must then be compared to the normal for each patient. The average sized man with a body surface area of 1.7 square meters has a normal liver weight of 1.5 kg ± 0.24 kg (one standard deviation). There are a limited number of variations found in radionuclide images of the liver and these are liver size, shape, and distribution of the radiopharmaceutical. The configuration of the normal liver as visualized in radionuclide images is quite variable as shown by McAfee et al. 44 They found that only 65 per cent of normal livers presented with a configuration similar to that usually illustrated in anatomic textbooks and 35 per cent had configurations readily identifiable as variants from the usual normal. Abnormal variations in shape that can be identified in radionuclide images are enlargement of the left lobe with or without contraction of the right lobe, a prominent incisura, and extension of the liver mass to the extreme left aspect of the abdominal cavity. In the normal liver the distribution of the radioactivity is usually quite uniform in both lobes. The variations that may be seen may present either as a generalized nonhomogeneity or as focal areas of decreased activity. Generalized nonhomogeneity of radioactivity suggests diffuse parenchymal disease whereas a discrete area of decreased radioactivity within the liver parenchyma suggests a mass lesion that may be a primary or secondary neoplasm, an abscess, or infrequently an angular or segmental area suggestive of postnecrotic cirrhosis. These changes in liver shape and distribution of radioactivity lack specificity and each may be caused by different pathologic processes. Of the abnormalities diagnosed by radionuclide imaging, hepatomegaly ranks as one of the most common. 44 The use of radionuclide imaging in the determination of the liver size is extremely useful since both the physical examination and plain roentgenograms of the abdomen are frequently inaccurate. The causes of hepatomegaly are numerous, and include such common etiologies as a fatty liver from toxic hepatitis, alcoholism, viral hepatitis (Fig. 13), hypertrophic cirrhosis (Fig. 14), biliary cirrhosis, lymphomas and leukemias, primary and secondary neoplasms (Fig. 7B), and hepatic enlargement as a result of congestion. Lesser frequently encountered basis for hepatomegaly are Gaucher's disease, amyloidosis, glycogen storage disease, Kwashiorkor's disease, Wilson's disease (Fig. 15), myeloid metaplasia and hepatic abscesses, particularly from amebiasis (Fig.10C). In the interpretation of radionuclide images, hepatomegaly should always be evaluated in conjunction with the spleenY Since the most commonly used radiopharmaceutical is 99mTc-S-colloid images of both the spleen and liver are obtained as well as the bone marrow and lung in some pathologic conditions. Correlative evaluations of the liver and the spleen are best made in the posterior view. In most normal posterior studies the concentration of sulphur colloid (labeled with 113mIn or 99mTc) per unit volume of the spleen approximates that of the liver or is slightly less. Generalized decreased reticuloendothelial function as manifest by less radioactivity per unit volume in the liver as compared to the spleen suggest parenchymal type disease such as fatty metamorphosis, hepa(Text continued on page 164.)

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Figure 13. A, This radionuclide image demonstrates hepatomegaly, splenomegaly, and nonhomogeneous distribution of radioactivity in the liver, which suggests diffuse parenchymal disease, such as hepatitis. B, Right and left hepatic venograms show no venous obstruction. The veins are normal in the grossly enlarged liver.

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Figure 14. A, The hepatic distribution of radioactivity in this scan is grossly nonuniform, but without areas of well defined decreases as are seen in tumors (see Figure 7B). The incisura is widened. Both the liver and the spleen are enlarged, and the concentration of radioactivity is greater in the spleen (a case of alcoholic cirrhosis). B, Selective arteriogram of the right hepatic artery. Tortuous arteries and nonhomogeneous distribution of the vasculature are noted in the enlarged liver. In hepatic cirrhosis, tortuosity of vessels is often present, but arteriography is not very reliable as a diagnostic tool.

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Figure 15. A, The liver is enlarged and extends over the spleen, which is massively enlarged. The distribution of radioactivity is non uniform, the incisura is widened, and the left lobe of the liver is hyperplastic. These findings are typical of cirrhosis Ca case of Wilson's disease). B, Celiac arteriogram shows hepatosplenomegaly. The enlargement of the left liver lobe is better appreciated by the radionuclide study.

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Figure 16. A, 99mTc sulfur colloid study demonstrates a large defect in the right lobe. The linear decreases of activity ·a re lead strips placed as markers over the inferior edge of the ribs. B, Gallium-67 study illustrates concentration of radioactivity in the right lobe, the region void of activity in the colloid study. This patient had a hepatocellular carcinoma.

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titis, or alcoholic cirrhosis. Comparison of reticuloendothelial function of the liver and spleen has been found to be very helpful in evaluating liver status in patients who have had intestinal bypass procedures for morbid obesity.19 Stimulation of other portions of the reticuloendothelial system, particularly the bone marrow and macrophages of the lung may also be reflected in colloid scans and is suggestive of decreased hepatic reticuloendothelial system function, and is indicative of parenchymal disease of the liver. Enlargement of the spleen is found in one third to one half of patients with primary carcinoma elsewhere than the liver whether hepatic metastases are present or not. Splenomegaly appears to be a response of the reticuloendothelial system to tumor similar to that which has been well demonstrated in laboratory animals. The magnitude of splenic enlargement found in association with primary carcinomas elsewhere is moderate, generally 50 to 150 per cent greater than normal. Ultrasonic Scanning B-Mode ultrasonic scanning promises to be a valuable and simple screening technique in investigation of hepatic disease. Presently focal lesions of 2 cm in size can be accurately detected by ultrasonic techniques. 23 , 51 Since it can usually differentiate between cystic and solid tumors it offers certain advantages over standard radionuclide studies (Fig. 17). In addition, ultrasonic control of hepatic needle biopsy increases the percentage of satisfactory specimens.51

Figure 17. An ultrasonic transverse section made 3 cm below the xyphoid process. The liver (L) is enlarged, occupies the right half of the abdominal cavity, and extends nearly to the left abdominal wall. In the right lobe laterally there is an irregular area of increased reflections (arrow) that represents a metastatic tumor. (Courtesy of Roger Sanders, M.D., Chief, Division of Ultrasonography, Department of Radiology, Johns Hopkins University, Baltimore, Maryland.)

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CONCLUSIONS Advances in radiographic equipment and techniques together with accumulated experience in vascular studies and scanning procedures of the liver have made it possible to investigate the liver in a direct approach. Since the causes of hepatomegaly are multiple, the diagnostic procedures for each patient must be individualized. Although guidelines can be established for the investigation of hepatomegaly, it is necessary to keep in mind the limitations of the diagnostic procedures. For example, scintigraphy and ultrasonic scanning are straight-forward screening procedures, usually devoid of risk. In a patient with known primary malignancy a hepatic mass detected by these procedures markedly increases the probability of a metastatic lesion. On the other hand, a negative scan does not exclude metastatic disease, particularly if the lesion is less than 2 to 3 cm in diameter. In some cases liver scans offer valuable diagnostic information for better understanding of findings at angiography. They should be preferred in investigation of parenchymatous hepatic disease and are usually satisfactory in following the results of given treatment, or after hepatic surgery. Of methodologies currently available, selective hepatic arteriography offers the most specificity for investigation of liver masses. The introduction of pharmacoangiography has largely replaced splenoportography including the investigation of portal hypertension. In patients with obstructive jaundice combined angiography with transhepatic cholangiography demonstrates not only the nature and extent of the disease but in addition the exact site of the biliary obstruction. 1, 10 All these procedures, however, do not eliminate the usefulness of less sophisticated contrast studies and plain abdominal or chest roentgenograms. In a jaundiced patient, drip infusion intravenous cholangiography may reveal the cause of biliary obstruction and make a transhepatic or transduodenal cholangiogram unnecessary. Barium studies of the alimentary tract (and intravenous urography) remain first choice procedures in the search for a primary neoplasm, and the simplest examination for detection of varices is still a properly performed barium examination of the esophagus.

REFERENCES 1. Agee, O. F., and Kaude, J.: A radiologic approach to obstructive jaundice and disease in the region of the pancreas. Surg. Gynec. Obstet., 132:614,1971. 2. Bierman, H. R., Kelly, K. H., Byron, R. L., Jr.: Hepatic arteriography. In Abrams, H. L., ed.: Angiography, Vol. 11. Boston, Little, Brown and Co., 1961, pp. 641-651. 3. Bierman, H. R., Miller, E. R., Byron, R. L., Jr., et al.: Intra-arterial catheterization of viscera in man. Amer. J. Roentgen., 66:555, 1951. 4. Bierman, H. R., Steinbach, H. L., White, L. P., et al.: Portal venipuncture: A percutaneous transhepatic approach. Proc. Soc. Exper. BioI. Med. N. Y., 79:550, 1952. 5. Blomberg, R., Larsson, L. E., Lindell, B., et al.: Late effects of thorotrast in cerebral angiography. Acta Radiol. (Diagn.), 1 :995, 1963. 6. Boijsen, E., and Abrams, H. L.: Roentgenologic diagnosis of primary carcinoma of the liver. Acta Radiol. (Diagn.), 3:257, 1965. 7. Boijsen, E., Kaude, J., and Tylen, U.: Antiography in hepatic rupture. Acta Radiol. (Diagn.), 11 :363, 1971.

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