imaging of cirrhosis
DESCRIPTION
Imaging of cirrhosis. Valérie Vilgrain Service de Radiologie Hôpital Beaujon France. Cirrhosis. Extensive fibrosis and regenerative nodules Main causesalcohol ingestion chronic hepatitis C chronic hepatitis B hemochromatosis Wilson disease Micronodularnodules < 3 mm - PowerPoint PPT PresentationTRANSCRIPT
Imaging of cirrhosis
Valérie Vilgrain
Service de RadiologieHôpital Beaujon
France
Cirrhosis
Extensive fibrosis
and regenerative nodules
Main causes alcohol ingestionchronic hepatitis Cchronic hepatitis BhemochromatosisWilson disease
Micronodular nodules < 3 mm
Macronodular larger nodules
Diagnosis
Liver diseases mimicking cirrhosis
Prognosis
Non invasive diagnosis of fibrosis
Diagnosis of cirrhosis
Nodularity of the liver surface
Nodular internal architecture
Changes of hepatic morphology
Vascular changes
Portal hypertension
Nodularity of the liver surfaceNodular internal architecture
Correlate with the gross appearance of cirrhosis
Surface. Initially described with high frequency
transducer. Seen with US, CT and MR
Internal architecture. Best seen with US and MR. Regenerative nodules hypoechoic - hypointense. Septa hyperechoic - hyperintense
Dilelio, Radiology 1989
CirrhosisSurface nodularity
Se SpAccuracy
Di Lelio 88 94 89Richard 58 86 81Ferral 88 82 84Ladenheim 13 88 76Colli 54 95
Radiology 1989J. Radiol 1985Gastrointest 1992Radiology 1992Radiology 2003
Hepatic morphologic changes
Hepatic morphologic changesQuantitative results (1)
Caudate lobe
Caudate-right lobe ratio (> 0.65)
Modified caudate-right lobe ratio (> 0.90)
Harbin, Radiology 1980Awaya, Radiology 2002
Hepatic morphologic changesQuantitative results (2)
Segment 4
Control group 43 ± 8 mm
Cirrhosis 28 ± 9 mm
Cutoff: 30 mm
Limit: measurement obtained at US
Lafortune, Radiology 1998
Hepatic morphologic changesOther signs
Expanded gallbladder fossaSpecificity and PPV of 98%
Associated with atrophy of the segment 4
Enlargment of hilar periportal spaceSeen in 98% in early cirrhosis Cutoff of 10 mm
. Control group: 5.3 mm
. Cirrhosis: 15.5 mm
Ito, Radiology 1999Ito, JMRI 2000
Vascular changes Hepatic veins
Normally triphasic
Cirrhosis
decreased diameter
altered waveform in 50%
correlated with the severity
reduced transit time (contrast US)
Bolondi, Radiology 1991Colli, AJR 1994Albrecht, Lancet 1999
HA diastolic velocity > PV velocity
Increased HA diameter
Increased RI and PI of the hepatic artery Portal vein velocity
Liver vascular index = -------------------------- Hepatic artery PI
< 12 cm/sec
Vascular changesHepatic artery
Iwao, Am J Gastroenterol 1997
Portal hypertension
Increased pressure > 15 mm Hg
Portocaval gradient > 5 mm Hg
Portal hemodynamicsCollateralsAscitesSplenomegaly
Diagnosis of PHTSplanchnic veins
Enlargment of splanchnic veins
Lack of caliber variations of SMV
Reversed flow SMV 2.1%splenic vein 3.1%
Alpern, Radiology 1987Bolondi, Radiology 1982
Diagnosis of PHT
Diameter of the portal vein > 13 mm Se 40%> 15 mm Se 12.5%
Alterations of portal blood flow abs of end-diastolic
arterialized flow
bidirectional flow
reversed flow 1%
Bolondi, Radiology 1982Vilgrain, Gastrointest Radiol 1990Lafortune 1990Gaiani, Gastroenterology 1991
Diagnosis of PHTLeft gastric vein
Diameter > 6 mm 26%
Hepatofugal flow 78%
Wachsberg, AJR 1994
Diagnosis of PHTGastroesophageal veins
Diagnosis of PHTParaumbilical vein
Diagnosis of PHTSplenorenal veins
Diagnosis of PHTOther collaterals
Retroperitoneal veins
Omental veins
Rectal varices
Gallbladder varices
Diagnosis of PHT
Mean portal velocity Mean portal blood flow
cm/sec ml/min
controls cirrhosis controls cirrhosis
Gaiani et al 19 2.1 11.4 3.7 919 285 1197 625
Moriyasu et al 15.3 4 9.7 2.6 899 284 870 289
Zoli et al 16 0.5 10.5 0.6 694 23 736 46
Ohnishi et al 17 3.9 12 3 648 186 690 258
Gaiani, Hepatology 1989Moriyasu, AJR 1986Zoli, J Ultrasound Med 1985Ohnishi, Gastroenterology 1985
CirrhosisUltrasound-Score
AccuracySurface nodularity+ mean portal velocity 82%
Spleen length 84%+ mean portal velocity
Spleen length 89%+mean portal velocity+hepatic venous spectrum Gaiani, J Hepatol 1997
Aubé, J Hepatol 1999Aubé, Eur J Gastroentrol 2004
Liver diseases mimicking cirrhosis
Common findings
Morphologic changes of the liverMay give signs of PHTGenerally vascular or biliary diseases
But
Rarely cause nodularity of the liver surfaceRarely have nodular regeneration
Primary sclerosing cholangitis
Lobular contour 73%
Caudate hypertrophy 98%
Lateral segment atrophy 58%
Posterior segment atrophy 36%
Dilated ducts 67%
End stage disease
Dodd, Radiology 1999
Congenital hepatic fibrosis
Mean age 39 years
Liver morphologic abnormalities 89%
Splenomegaly 83%
Varices 78%
Renal abnormalities 56%
Ductal plate malformation 50%
Zeitoun, Radiology 2004
Congenital hepatic fibrosis
Hypertrophy of the left lateral
Normal or hypertrophy of the segment 4
Atrophy of the right lobe
Zeitoun, Radiology 2004
Budd-Chiari disease
Hypertrophy of the caudate lobe > 50%
Lobar atrophy/hypertrophy
Abnormal hepatic veins
Hepatic venous collaterals
Portal cavernoma
Central vs peripheral zone
Vilgrain, Radiology 2006
Imaging in assessing prognosis?
Comparison between compensated and uncompensated cirrhosisSerial imaging
Stability and functional reserve. Hypertrophy and increasing of the caudate lobe 1, 2, 3
. High caudate to right lobe ratio 1
. Increasing lateral segment 2
Clinical progression. Progressive atrophy of the right lobe and medial segment 2
. Spleen enlargment 3
. Varices 31. Watanabe, Dig Dis Sci 19992. Ito, Radiology 19983. Ito, AJR 1997
Limitations of non invasive imaging
Most signs seen in advanced cirrhosis
No specific signs associated with fibrosis
=> Need to find other criteria
other imaging
Diagnosis of fibrosis
Blood tests: Fibrotest
Elastrography
Liver MR diffusion
Liver perfusion
FibrotestAlpha 2 macroglobulin
Haptoglobin
Apolipoprotein 1
Total bilirubin
GGT
ALT
0 - 0.10 Probability of fibrosis < 10%
0.10 - 0.60 Liver biopsy recommended
0.60 - 1.00 Probability of fibrosis > 90%Imbert-Bismuth, Lancet 2001
Elastography (Fibroscan)
Ultrasound (5MHz) and low frequency (50 Hz) elastic wavesPropagation velocity is related to elasticity
Liver MR diffusion
Reduced ADC in cirrhosis
Taouli, Radiology 2003
Liver perfusion
Van Beers, AJR 2001
CONCLUSION
Today, non invasive imaging is crucial for diagnosing cirrhosis and its complications.
Tomorrow, the challenge of imaging will be to detect early stages of fibrosis and cirrhosis and to demonstrate therapeutic response.