Radiographic Evidence of Liver
Cirrhosis & Sequelae
Ashley Evans, MS3
Liver Cirrhosis
• Cirrhosis is the result of:
 Alcoholic liver disease
 Viral hepatitis
 Primary biliary cirrhosis
 Primary sclerosing cholangitis
 Congestive hepatopathy,
 Wilson’s disease,
 Hemochromatosis,
In North America, ~75% of cirrhosis cases are attributed to
chronic alcoholism1
Cirrhosis
• Among the leading causes of death in the
western world
• Pathologically defined by 3 main
characteristics:
– Fibrosis
– Nodular transformation
– Distortion of hepatic architecture
Pathophysiology of Cirrhosis
Insult to Liver Cells
Cell Necrosis and
Regeneration
Diffuse Fibrosis
Regenerating Nodules
Destruction of Histological Structure
Hallmark Findings
• Nodular Liver
• Portal Hypertension
• Hepatofugal Portal Venous Flow
– Portosystemic Vascular Shunts
• Esophageal varices
• Gastric varices
• Superficial abdominal wall collaterals
– Ascites
– Splenomegaly
• Hepatocellular Carcinoma
• Hepatopulmonary Syndrome
Why Do We Image?
• Characterize the
morphologic
manifestations of the
disease
• Evaluate the hepatic
and extrahepatic
vasculature
• Assess the effects of
portal hypertension
• Detect hepatic
tumors
Numminen, et al. Scandinavian Journal of Gastroenterology; 2005
Imaging Options
CT Scan
MRI
Ultrasound
Angiography
Murakami, Seminars, 2001.
Cirrhosis:
Characteristic Findings
• Nodularity
CT Normal
– Best seen affecting the liver
margin (especially left
lateral)
• Cobblestone appearance
• Diffuse heterogeneity of
liver parenchyma
• Atrophy of the right lobe
and hypertrophy of the left
and caudate lobes
Van Beers, et al. AJR; 2001
MRI Chronic
Cirrhosis
Murakami, Seminars, 2001.
Cirrhosis:
Early Imaging Changes
• Enlargement of the
hilar periportal space
• Enlargement of the
major interlobar
fissure
• Expansion of
pericholecystic space
or gallbladder fossa
Numminen, et al. Scandinavian Journal of Gastroenterology; 2005
Portal Hypertension
• Responsible for the most devastating
complications of end-stage liver disease:
– Upper GI bleeding
– Ascites
– Hepatic encephalopathy
Portal Hypertension
• Extensive fibrosis of the spaces of Disse
• Nodular regeneration
– Resistance to sinusoidal blood flow
– Intrahepatic mesenteric vasodilators
– Extra- and intrahepatic portosystemic
anastomoses develop to divert some portal
venous blood directly into the systemic venous
circulation
Kang, et al. Radiographics: 2002
Hepatofugal Blood Flow
79 yoF with alcoholic cirrhosis
The finding of a
small main
portal vein
strongly
correlates with
hepatofugal
flow6
Bryce, et al. AJR; 2003
Hepatofugal Blood Flow
49yoM Hep C cirrhosis
Enhancement of
the portal vein
during arterial
phase indicates
hepatofugal portal
venous flow6
Bryce, et al. AJR; 2003
Portosystemic Vascular Shunts
• Variceal hemorrhage is a devastating
complication that occurs in 25 to 40
percent of patients with cirrhosis
–
–
–
–
–
Gastroesophageal collaterals
Superficial collaterals
Splenorenal shunts
Retroperitoneal and mesenteric collaterals
Transhepatic Portosystemic collaterals
• Recanalized paraumbilical vein
• Hepatic surface collaterals
Esophageal Varix
CT scan shows a
tortuous, enlarged
paraesophageal
varix (arrows).
Kang, et al. Radiographics: 2002
Gastric Varix
Axial CT scan
shows dilated
left gastric vein
between the
anterior wall of
the stomach and
the posterior
surface of the
left hepatic lobe
Kang, et al. Radiographics: 2002
Anterior Abdominal Wall
Collaterals
• CT appearance of the
anterior abdominal
wall in a normal
patient at the level of
the umbilicus
• CT showing multiple
collateral superficial
veins
Groves, et al. BJR; 2002
What is the significance of
collateral vessels?
Groves, et al. BJR; 2002
The maximal number of superficial collaterals on a
CT image was significantly greater (p<0.02) in a
cirrhotic cohort than a control cohort
Ascites
• Def: accumulation of fluid within the peritoneal
cavity
• Most common complication of cirrhosis
– Due to elevated portal pressures, low albumin levels
• Nearly 60% of patients with compensated
cirrhosis will develop ascites in 10 years
– 2 year survival of patients with ascites is ~50%8
• Can develop into spontaneous bacterial peritonitis
(SBP)
Ascites
• In most cases, the
attenuation of the ascites is
that of clear fluid,
measuring around 0 HU
• If the attenuation of ascitic
fluid is significantly greater
than 0 HU, this should raise
concern for hemorrhage or
SBP
T2 weighted MRI with fluid
around right lobe
Chopra, et al. Radiology; 1999
CT scan demonstrating ascites
Bryce, et al. AJR; 2003
Splenomegaly
• Common in patients with severe portal
hypertension
• Although the spleen may become massive,
it is usually asymptomatic
• May contribute to the thrombocytopenia or
pancytopenia of cirrhosis
Splenomegaly
T1-weighted MRI
demonstrates
nodular liver,
fibrosis,
splenomegaly.
Murakami, Seminars, 2001.
Hepatocellular Carcinoma
• Risk of HCC in patients with cirrhosis due
to hepatitis C is approximately 100x the risk
of non-infected cirrhotics (alcoholic
cirrhosis is 2-3x increased risk)1.
• Incidence is rising in the United States
– Has almost doubled over the past 20 years,
most likely due to rising incidence of Hep C
Detection of HCC
• Commonly diagnosed
by ultrasound on
routine screens of
cirrhotic livers
• CT and MRI are
useful to characterize
any hepatic tumors
detected by US
Ultrasound of welldifferentiated HCC
Murakami, Seminars, 2001.
Hepatocellular Carcinoma
HCC show in
precontrast CT (left),
arterial phase (middle)
and equilibrium phase
(right).
Large HCC shown by
T1 spin echo (left) and
T2 spin echo (right).
Detection of HCC
• Detection of liver lesions is dependent on
contrast difference between normal
parenchyma and the nodules.
– This is affected by cellularity, fibrosis, fatty
change and vascularity of nodules
• Arterial phase CT scan is thought to be the
most useful technique for detecting
hypervascular tumors such as HCC.
Hepatopulmonary Syndrome
• Defined by the triad of:
– Liver disease
– Increased A-a gradient on room air
– Evidence for intrapulmonary vascular
abnormalities
• Signs and symptoms:
– Dyspnea, platypnea, orthopnea
Hepatopulmonary Syndrome
• On CT scans, pulmonary
vessels are enlarged, do
not taper normally,
extend to the pleural
surface, and are most
numerous in the bases
• The ratio of the diameter
of the segmental arteries
to the diameter of the
accompanying bronchi is
increased in
hepatopulmonary syn.
Lee, et al. Radiology; 1998.
The End
References
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