Cirrhosis

Published on 19/07/2015 by admin

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Last modified 19/07/2015

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 Hyperdense on NECT, isodense on CECT

image Hypointense on T2 and GRE MR
image 3-10 mm in size
• Vascular derangements

image Arterioportal and portovenous shunts
image Varices (gastroesophageal, caput medusae, etc.)
• Fibrosis: Diffuse, lace-like, thick, or confluent foci

image Hypointense on T1W; hyperintense on T2W MR
• Cirrhosis-induced hepatocellular carcinoma (HCC)

image Heterogeneous enhancement on arterial phase; usually hypodense on venous and delayed phase CT + MR
image Hyperintense on T2W MR
image Bright on DWI MR
image ± capsule, fat, venous invasion, metastases

TOP DIFFERENTIAL DIAGNOSES

• Treated liver metastases or lymphoma
• Budd-Chiari syndrome
• Hepatic sarcoidosis
• Primary portal vein thrombosis
• Nodular regenerative hyperplasia

DIAGNOSTIC CHECKLIST

• MR has advantage in detection and characterization of focal nodules within cirrhotic liver
image
(Left) Graphic shows a cirrhotic liver with a nodular surface contour and an increase in the caudate to right lobe ratio, measured from the branch point of the right portal vein image to the edges of the caudate and right lobes, respectively. Note the bands of fibrosis image and ascites.

image
(Right) Axial CECT shows a cirrhotic liver and large varices image. Note the enlarged caudate lobe image, which is as wide as the right lobe, although the caudate lobe is normally no more than 60% of the width of the right lobe.
image
(Left) Axial NECT in this 50-year-old woman with primary biliary cirrhosis shows innumerable small hyperdense regenerative nodules image, surrounded by lace-like fibrosis.

image
(Right) The nodules disappear into the background cirrhotic liver on this CECT from the same patient. Prominent porta hepatis lymphadenopathy image, another typical feature of primary biliary cirrhosis, is also noted. Primary biliary cirrhosis is an autoimmune disease that typically affects women in their 5th or 6th decade.

TERMINOLOGY

Definitions

• Chronic liver disease characterized by diffuse parenchymal injury, extensive fibrosis, and conversion of liver architecture into structurally abnormal nodules

IMAGING

General Features

• Best diagnostic clue

image Nodular contour, widened fissures, and enlarged caudate lobe with ascites, splenomegaly, and varices
• Size

image Moderate to advanced cirrhosis: Decreased size

– Earlier disease: May be enlarged
– Especially in primary biliary cirrhosis
• Key concepts

image Common end response of liver to variety of insults and injuries
image Classification by morphology (not very useful)

– Micronodular (Laennec) cirrhosis

image Usually due to alcoholism
– Macronodular (postnecrotic) cirrhosis

image Usually viral hepatitis
image Classification by etiology and severity more useful

CT Findings

• Atrophy of right lobe and medial segment of left lobe
• Enlarged caudate lobe and lateral segment of left lobe

image Caudate: Right lobe ratio often > 1.0 in cirrhosis
image Caudate is normally < 60% width of right lobe
• Widened fissures between segments/lobes
• Deep gallbladder (GB) fossa

image GB often lies against anterolateral abdominal wall
• Vascular derangements

image Varices (gastroesophageal, caput medusae, etc.)
image Arterioportal and portovenous shunts

– Arterioportal (AP) shunts are usually peripheral, wedge-shaped, small; seen only on arterial phase
– Small AP shunt difficult to distinguish from very small hepatocellular carcinoma (HCC)

image Follow-up imaging (CT or MR) in 3-6 months is sufficient for surveillance
image “Corkscrew” hepatic arterial branches

– Enlarged and displaced around regenerative nodules
• Splenomegaly
• Nodular liver contour (not apparent in all)
• Siderotic regenerative nodules

image Hyperdense on NECT, isodense on CECT
image Most regenerative nodules are not detected by CT
• Fibrotic and fatty changes

image Fibrosis: Diffuse, lace-like, thick bands or confluent “masses”

– More apparent on NECT (hypodense)
– May show persistent enhancement on delayed CECT (or contrast-enhanced MR)

image Distinguishes from HCC, which shows washout on delayed imaging
image Fatty changes: Diffuse or geographic areas of low attenuation

– Usually limited to alcoholic hepatitis with early cirrhosis
• Peribiliary cysts

image Cystic dilation of peribiliary gland in wall of large bile ducts
image Range in size from 2 mm to 2 cm
image Resemble string of pearls or grapes on a stem
• Cirrhosis-induced HCC

image NECT: Hypodense or heterogeneous, ± fat
image CECT

– Heterogeneous enhancement on arterial phase; usually iso- to hypodense on venous and delayed phase scans
– ± capsule, portal or hepatic venous invasion, metastases

MR Findings

• Siderotic regenerative nodules: Paramagnetic effect of iron within nodules

image T1WI: Hypointense
image T2WI: Increased conspicuity of low signal intensity
image T2 gradient-echo and fast low-angle shot (FLASH) images

– Markedly hypointense (best sequence for detection)
image Gamna-Gandy bodies (siderotic nodules in spleen)

– T1WI and T2WI: Hypointense
• Dysplastic regenerative nodules

image T1WI: Hyperintense; T2WI: Hypointense

– Opposite to usual pattern for HCC
image Minimal vascularity
image Take up and retain hepatobiliary MR contrast agents on delayed phase

– Most specific test to distinguish from HCC
• HCC nodule

image T1WI: Iso-, hypo-, or hyperintense
image T2WI: Hyperintense
image T1 C+: Increased enhancement on arterial phase

– Washes out to hypointense on venous and delayed phases
image Diffusion-weighted imaging

– Restricted diffusion (bright signal) within HCC
image Rarely take up or retain hepatobiliary MR contrast agents
• Fibrotic and fatty changes

image T1WI: Fibrosis = hypointense; fat = hyperintense
image T2WI: Fibrosis = hyperintense; fat = hypointense
• MR elastography

image Shows promise in noninvasive evaluation of extent of liver fibrosis

Ultrasonographic Findings

• Grayscale ultrasound

image Nodular liver contour and parenchyma
image Increased and coarsened liver echogenicity

– Decreased visualization of deep liver
image Atrophy of right lobe and medial segment of left lobe
image Features of portal hypertension

– Increased pulsatility of portal vein Doppler tracing
– Dilated hepatic and splenic arteries with increased flow
• Color Doppler

image Used to determine portal vein patency and direction of flow

– Hepatopetal is normal
– Hepatofugal is sign of severe portal hypertension
• Ultrasound is of most value and accuracy in screening patients with less advanced chronic liver disease

image Less accurate in detecting or characterizing nodules within cirrhotic liver
image Presence of fibrosis, fat, regenerative nodules makes detection of HCC very difficult

Imaging Recommendations

• Best imaging tool

image Multiphasic CT or MR
• Protocol advice

image US is suitable for screening until cirrhosis is established
image CECT is preferable in acutely ill patients or those with ascites
image MR is preferable in alcoholic cirrhosis and for detection/distinction of hepatic nodules

– Include delayed phase MR or CT (5-10 minutes)
– Hepatobiliary MR contrast agents may aid in detection of HCC

image Gadoxetate (Eovist, Primovist) is retained in normal liver, variably in cirrhotic liver, rarely in HCC

DIFFERENTIAL DIAGNOSIS

Treated Liver Metastases or Lymphoma

• Simulates nodules, fibrosis, volume loss of cirrhotic liver
• Breast carcinoma metastases to liver

image May result in “pseudocirrhosis,” especially after treatment

Budd-Chiari Syndrome

• Liver damaged but usually no bridging fibrosis

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