Passive Hepatic Congestion

Published on 19/07/2015 by admin

Filed under Radiology

Last modified 19/07/2015

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 Early retrograde enhancement of dilated inferior vena cava (IVC) and hepatic veins (HVs)

image Heterogeneous, mottled, reticulated, mosaic hepatic parenchymal pattern
image Periportal low attenuation (perivascular lymphedema)
image Hepatomegaly and ascites
• US: Loss of normal triphasic flow pattern

image Spectral signal may have “M” shape
image Cardiac cirrhosis: Flattening of Doppler wave form in hepatic veins
image “To and fro” motion in hepatic veins and IVC

TOP DIFFERENTIAL DIAGNOSES

• Budd-Chiari syndrome
• Hepatic cirrhosis
• Acute viral hepatitis

CLINICAL ISSUES

• Passive hepatic congestion usually secondary to

image Congestive heart failure
image Constrictive pericarditis
image Tricuspid insufficiency
image Right heart failure
• Radiologists may be 1st to recognize cardiac source of liver disease
• Diagnosis is based on clinical and imaging findings

DIAGNOSTIC CHECKLIST

• Differentiate acute passive hepatic congestion from Budd-Chiari and viral hepatitis
• Distinguish chronic, cardiac cirrhosis from other etiologies
image
(Left) Graphic shows massive diffuse dilatation of the hepatic veins and mildly heterogeneous liver parenchyma due to passive congestion of the liver.

image
(Right) Axial CECT in the arterial phase shows early retrograde opacification of dilated hepatic veins image and the inferior vena cava (IVC) due to reflux of injected contrast medium through the heart, a sign of impaired antegrade hepatic venous drainage.
image
(Left) Increased pulsatility of portal vein Doppler signal image is demonstrated in this patient with passive hepatic congestion secondary to tricuspid insufficiency.

image
(Right) Transverse ultrasound shows dilated hepatic veins image and IVC in a patient with passive hepatic congestion.

TERMINOLOGY

Synonyms

• Congested liver in cardiac disease

Definitions

• Stasis of blood within liver parenchyma as result of impaired hepatic venous drainage

IMAGING

General Features

• Best diagnostic clue

image Dilated hepatic veins with “to and fro” blood flow on color Doppler US
• Key concepts

image Hepatic manifestations of cardiac disease

– Acute manifestation: Enlarged, heterogeneous liver
– Late manifestation: Cardiac cirrhosis, small liver that may resemble cirrhosis of other causes
image Passive hepatic congestion usually secondary to

– Congestive heart failure (CHF)
– Constrictive pericarditis
– Tricuspid insufficiency
– Right heart failure (e.g., pulmonary artery obstruction caused by lung cancer)
image Characteristic sign on physical exam

– Hepatojugular reflux

CT Findings

• Early retrograde enhancement of dilated inferior vena cava (IVC) and hepatic veins (HVs)

image Due to contrast reflux from right atrium into IVC
• Heterogeneous, mottled hepatic parenchymal pattern on arterial &/or venous phase CECT

image Due to delayed enhancement of smaller hepatic veins
• Peripheral, large, patchy areas of poor or delayed enhancement
• Periportal low attenuation (perivascular lymphedema)

image Decreased attenuation around intrahepatic IVC
• Hepatomegaly and ascites
• Chest findings vary by type of cardiac disease

image Small heart due to constrictive pericarditis
image Cardiomegaly due to valvular heart disease or cardiomyopathy
image ± pericardial or pleural effusions

MR Findings

• T2WI

image Periportal high signal intensity (periportal edema)
• T1WI C+

image Same dilated IVC and HVs as seen on CECT
image Mottled hepatic enhancement
• MRA

image Slow or absent antegrade flow within IVC

Ultrasonographic Findings

• Grayscale ultrasound

image 

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