cirrhosis & portal hypertension: radiologic findings
TRANSCRIPT
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Nazleen Bharmal
Gillian Lieberman, MD
Nazleen
BharmalHarvard Medical School Year III
Gillian Lieberman, MD
March 2002
Cirrhosis & Portal Hypertension: Radiologic Findings
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2
Nazleen Bharmal
Gillian Lieberman, MD
•
HPI –
50 year-old male presents with confusion
•
PMH –
alcoholism, s/p
cholecystectomy
•
PE –
jaundice, positive abdominal fluid wave
•
Labs –
Abnormal LFTs: nl
aminotransferases, ↑
TBili, ↑
PT, ↓
Alb, ↑
Ammonia, ↑
Alk
Phos
Our Patient
•
Impression –
Alcoholic cirrhosis, Hepatic encephalopathy
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3
Nazleen Bharmal
Gillian Lieberman, MD
Menu of Tests•
Ultrasound (US)
•
Computed tomography (CT)
•
Magnetic resonance imaging (MRI)
•
Nuclear medicine
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4
Nazleen Bharmal
Gillian Lieberman, MD
courtesy of BIDMC PACS
Ultrasound of Liver
Ascites
Liver
Our Patient: US Imaging
Doppler studies: patent portal & hepatic veins
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Nazleen Bharmal
Gillian Lieberman, MD
Differential Diagnosis: Hepatic Ascites*
SinusoidalCirrhosis (81%)
SBP
Hepatitis
Liver Metastases
HCC
Post-Sinusoidal• Constrictive pericarditis
• Right-sided CHF
• Tricuspid insufficiency
• Budd-Chiari
syndrome
• Veno-occlusive disease
Pre-Sinusoidal•
Portal or Splenic vein thrombosis
• Schistosomiasis
* Portal Hypertension-Related Etiologies
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Nazleen Bharmal
Gillian Lieberman, MD
Hepatic Anatomy
Sullivan, Lisa. The Liver, Biliary System, and Pancreas. Juhl: Paul and Juhl's Essentials of Radiologic Imaging, 7th ed., Lippincott Williams & Wilkins, 1998.
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Nazleen Bharmal
Gillian Lieberman, MD
CT Abdomen with IV contrast courtesy of BIDMC PACS
CT Abdomen: NormalPatient 1
Aorta
Liver Stomach
Spleen
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8
Nazleen Bharmal
Gillian Lieberman, MD
courtesy of BIDMC PACS
CT Abdomen with IV contrast
Stomach
SpleenAscites
Nodular Liver
Our Patient: CT Imaging
?Falciform
ligament
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Nazleen Bharmal
Gillian Lieberman, MD
Our Patient: Diagnosis
Netter, F.H. The CIBA Collection of Medical Illustrations, Volume 3: Digestive System, Part III, 1957
Liver Cirrhosis
Portal Hypertension
Ascites, Varices, Splenomegaly, Encephalopathy
LIVER CIRRHOSIS
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Nazleen Bharmal
Gillian Lieberman, MD
Netter, F.H. The CIBA Collection of Medical Illustrations, Volume 3: Digestive System, Part III, 1957
Portal Hypertension Signs & Symptoms
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Nazleen Bharmal
Gillian Lieberman, MD
Netter, F.H. The CIBA Collection of Medical Illustrations, Volume 3: Digestive System, Part III, 1957
Portal System: Portacaval
Anastomoses
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Nazleen Bharmal
Gillian Lieberman, MD
CT Abdomen with IV contrast courtesy of BIDMC PACS
Our Patient
Esophageal Varices
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Nazleen Bharmal
Gillian Lieberman, MD
Esophageal Varices: Another Look
Netter, F.H. The CIBA Collection of Medical Illustrations, Volume 3: Digestive System, Part I, 1957
Normal Anatomy
Abnormal Anatomy
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Nazleen Bharmal
Gillian Lieberman, MD
Esophageal Varices: Barium Study
http://mycourses.me
d.harvard.edu/collec
tion_display.asp?tas
k=framer&tn=y&lo
okupGUID=Head{0
193EB25-8547-
4D1D-BE9E-
31E85A142F65}
http://mycourses.med
.harvard.edu/collectio
n_display.asp?task=fr
amer&tn=y&lookup
GUID=Head{33ACA
E5C-C5E8-4D1F-
A23F-
626B72EBF9DC}
Normal Abnormal
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Nazleen Bharmal
Gillian Lieberman, MD
Esophageal Varices: Endoscopy
http://medlib.med.utah.edu/WebPath/GIHT
ML/GI121.hmtl http://home.t-online.de/home/afreytag/o06e.htm
Normal Abnormal
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16
Nazleen Bharmal
Gillian Lieberman, MD
CT Abdomen with IV contrast courtesy of BIDMC PACS
CT Abdomen: NormalPatient 1
Aorta
Liver Stomach
Spleen
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Nazleen Bharmal
Gillian Lieberman, MD
CT Abdomen with IV contrast courtesy of BIDMC PACS
Our PatientGastric Varices
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Nazleen Bharmal
Gillian Lieberman, MD
CT Abdomen with IV contrast courtesy of BIDMC PACS
Our PatientMore Varices
–
Spleen & Bowel
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Nazleen Bharmal
Gillian Lieberman, MD
courtesy of BIDMC PACS
Patient 2
SplenomegalyPatient 3
Ascites
CT Abdomen w/ IV contrast
Anasarca
MR Abdomen T2 Coronal
Ascites
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Nazleen Bharmal
Gillian Lieberman, MD
CT Abdomen without IV contrast courtesy of BIDMC PACS
One More Finding…Our Male Patient
Gynecomastia Gynecomastia
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Nazleen Bharmal
Gillian Lieberman, MD
Our Patient: Course
• High risk for UGIB and HCC
•Intractable Ascites
–
TIPS procedure
• Liver Transplant
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Nazleen Bharmal
Gillian Lieberman, MD
courtesy of BIDMC PACS
TIPS ProcedureOur Patient
TIPS stent with contrast demonstrates flow from portal vein to IVC, thus bypassing the liver
Angiogram
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Nazleen Bharmal
Gillian Lieberman, MD
courtesy of BIDMC PACS
TIPS Procedure: US Imaging
Liver Ultrasound
Liver
Stent
Our Patient
Ascites
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Nazleen Bharmal
Gillian Lieberman, MD
courtesy of BIDMC PACS
TIPS Procedure: Color Doppler US
Liver UltrasoundOur Patient
• Patent TIPS
•
Red = flow towards transducer
•
Blue = flow away from transducer
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Nazleen Bharmal
Gillian Lieberman, MD
The TIPS procedure relieved the ascites
somewhat. Our patient
went on to receive a liver transplant.
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Nazleen Bharmal
Gillian Lieberman, MD
References•
Netter, F.H. The CIBA Collection of Medical Illustrations, Volume 3: Digestive System, Part III. CIBA-Geigy, Summit, 1957
•
Netter, F.H. The CIBA Collection of Medical Illustrations, Volume 3: Digestive System, Part I. CIBA-Geigy, Summit, 1957
•
Sabatine, Marc S., MD editor. Pocket Medicine. Lippincott Williams & Wilkins. Philadelphia: 2000. 3-20, 3-22.
• Gamuts, Radiology Texts, UptoDateonline
•
Sullivan, Lisa. The Liver, Biliary System, and Pancreas. Juhl: Paul and Juhl's Essentials of Radiologic Imaging, 7th ed., Lippincott Williams & Wilkins, 1998, pgs 511-514.
• Brown JJ, Naylor MJ, Yagan
N. Imaging of Hepatic Cirrhosis. Radiology 202:1-13, 1997.
•
Taylor HM, Ros
PR. Hepatic Imaging. Radiologic Clinics of North America 36(2):237-44, March 1998.
•
Portal Hypertension. The Merch Manual Section 4:Chapter 38, Merck & Co, Inc. New Jersey:2001
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Nazleen Bharmal
Gillian Lieberman, MD
Acknowledgements• Pamela Lepkowski
• Gillian Lieberman, MD
• Daniel Saurbour, MD
• Haldon
Bryer, MD
• Ravi Thakur, MD• Larry Barbaras and Cara Lyn D’amour