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Cirrhosis and Portal Hypertension

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Cirrhosis and Portal Hypertension Radiology Case
Image showing coronal post contrast CT image of abdomen in a case of liver cirrhosis withh portal hypertension, ascites, portal colopathy.

Quiz

Which of the following is a feature of this pathology?

  1. Caudate lobe atrophy
  2. Right lobe hypertrophy
  3. Caudate lobe hypertrophy

Key Imaging Features:

Ultrasound:

B mode:

  • Surface nodularity.
  • Coarse echotexture- pinhead echoes, inhomogenous in distribution, with no posterior shadows.
  • Regenerative nodules.
  • Caudate lobe hypertrophy (caudate / right lobe ratio > 0.65).
  • Poor visualization of hepatic vessels.
  • Splenomegaly (mid axillary length >13cm or largest cross sectional area through the hilum > 45 square cm).
  • Gamna Gandy nodules: Multiple hyperechogenic nodules due to microbleed foci in the spleen and siderotic changes.
  • Splenic interface sign: Linear hyperreflective channels in splenic parenchyma due to dilated intrasplenic venous sinuses with deposition of collagen in the walls.
  • Increase in bowel wall and gallbladder wall thickness due to edema.

Color Doppler:

Alteration in normal doppler findings and spectral traces of portal vein, hepatic artery and hepatic vein.

Schematic of Doppler study showing spectral traces in hepatic artery, hepatic vein, and portal vein under normal conditions and with portal hypertension.
Figure showing schematic representation of doppler study and spectral traces in hepatic artery, hepatic vein and portal vein in normal conditions vs. portal hypertension
  • Visualization of collaterals and varices on color doppler. Following are a few schematic diagrams describing ultrasound and doppler features.
Line diagrams illustrating ultrasound and Doppler findings in portal hypertension, showing changes in blood flow patterns and vessel structure.
Image showing schematic representations with easy to draw line diagrams of ultrasound and doppler findings in the case of portal hypertension.
Schematic line diagrams of ultrasound and Doppler findings in portal hypertension, highlighting altered blood flow and vessel structure.
Image showing schematic representations with easy to draw line diagrams of ultrasound and doppler findings in the case of portal hypertension.
Schematic diagrams of Doppler ultrasound findings of the coronary vein, comparing normal conditions with portal hypertension, using simple line drawings to show blood flow differences.
Image showing schematic representations with easy-to-draw line diagrams of doppler findings of coronary vein in normal conditions vs. the case of portal hypertension.
Schematic diagrams showing ultrasound, Doppler, and axial CT/MRI findings of the paraumbilical vein in portal hypertension. The illustrations use simple line drawings to depict the abnormal blood flow and structural changes associated with portal hypertension.
Image showing schematic representations with easy-to-draw line diagrams of ultrasound, doppler and axial CT/MRI  findings of paraumbilical vein in  portal hypertension.
  • Summarized list of features on doppler is as follows:
Alt text: "List comparing Doppler ultrasound features of the paraumbilical vein under normal conditions versus portal hypertension. The comparison highlights the differences in blood flow patterns and vein structure between the two states."
List of doppler features in normal conditions vs. portal hypertension
Continuation of a list comparing Doppler ultrasound features of the paraumbilical vein in normal conditions versus portal hypertension. The list details additional differences in blood flow patterns and vein structure between the two states.
List of doppler features in normal conditions vs. portal hypertension(continued).
Continuation of a list comparing Doppler ultrasound features of the paraumbilical vein in normal conditions versus portal hypertension. It further outlines differences in blood flow characteristics and structural changes specific to portal hypertension.
    List of doppler features in normal conditions vs. portal hypertension (continued).

Contrast enhanced ultrasound:

  •     Role of contrast enhanced ultrasound is described in the following chart.
Schematic representations with simple line diagrams illustrating contrast ultrasound findings in cirrhotic livers. The diagrams highlight typical imaging features and patterns associated with cirrhosis, aiding in the differentiation from normal liver tissue.
Image showing schematic representations with easy-to-draw line diagrams of contrast ultrasound findings in cirrhotic livers.

Elastography:

  •     TE and acoustic radiation force impulse (ARFI) are most commonly used.
  •    > 7 kPa: Advanced fibrosis

  >12.5 – 15 kPa: Cirrhosis

CT:

Liver-

  • Surface irregularity.
  • Caudate to right lobe ratio increased > 0.65.
A summary providing a simple explanation of the calculation and interpretation of the caudate to right lobe ratio. The summary outlines the steps to measure the ratio and its significance in medical diagnostics, particularly in assessing liver conditions.

Easy to understand summary on calculation and interpretation of causate to right lobe ratio.

  • Nodules –
    • Regenerative: Iso or hyperattenuating;
    • Siderotic: Hyperattenuating.
    • Malignant : Enhance in early arterial phase (20 seconds after contrast injection), show washout of contrast on delayed phase images.
  • Confluent fibrosis appears hypoattenuating on non-contrast CT and isoattenuating or slightly hypoattenuating on contrast CT images.
  • Splenomegaly.
  • Ascites.
  • Lymphadenopathy in advanced cases.
  • Enlarged portal vein, splenic vein, superior mesenteric vein.
  • Collaterals delineated on contrast CT and angiography images.
Schematic representations and simple line diagrams illustrating axial and coronal views of collateral vessels in cases of portal hypertension. The diagrams highlight the formation and distribution of collateral vessels, aiding in the understanding of their appearance and significance in this condition.
Schematic representations and easy-to-draw line diagrams of axial and coronal findings of collateral vessels in case of portal hypertension.

MRI-

  • Morphological changes- Irregular contours, atrophy of right lobe of liver,hypertrophy of caudate lobe.
  • Comma shaped intrahepatic varices seen on TOF images.
  • Vascular anatomy seen with GRE images.
  • Phase contrast MR Angiography sequence for direction of portal flow.
  • MR Elastography : >4 kPa in fibrotic liver.
  • Nodules: Regenerative, Dysplastic, Malignant nodules can be characterized.  A chart summarizing the common patterns on cross sectional imaging is as follows:
A summarized list detailing and differentiating CT and MRI features of liver nodules in a cirrhotic liver. The list includes key characteristics and distinguishing clues to help identify and differentiate various types of liver nodules on imaging studies.
Summarized list and differentiating clues regarding CT and MRI features of liver nodules in cirrhotic liver.
Simple line diagram illustrating the 'nodule in nodule' appearance characteristic of hepatocellular carcinoma in cirrhotic livers, as depicted on MRI. The diagram provides a summary of key features aiding in the recognition and diagnosis of hepatocellular carcinoma within the context of cirrhosis.
Easy-to-draw line diagram of ‘nodule in nodule’ appearance and summary of features of hepatocellular carcinoma in cirrhotic livers as seen on MRI.

Pathophysiology

A summarized flowchart depicting the sequence of pathologies and their respective features observed at the diagnosis of cirrhosis. The flowchart outlines the progression of liver disease and the characteristic manifestations encountered during the diagnostic process.
Summarized flow chart on sequence of pathologies and the respective features that are manifested at diagnosis of cirrhosis.

As the liver becomes too stiff due to fibrosis, it cannot effectively drain blood via the hepatic veins into the inferior vena cava. The pressure builds up in the portal vessels and flow reverses away from the liver. Collateral circulation becomes active to bypass the liver in draining blood to the heart.

The next two images show line diagrams of normal portal and systemic blood flows, and altered portosystemic shunts.

A simple line diagram illustrating the normal direction of portal and systemic flow. The diagram visually represents the physiological pathways of blood circulation in the body, distinguishing between portal circulation and systemic circulation.
Easy-to-draw line diagram on normal direction of portal and systemic flow.
A simple line diagram illustrating the altered direction of portal and systemic flow in the case of cirrhosis. The diagram visually depicts the abnormal blood circulation patterns that occur in cirrhotic livers, highlighting the changes in flow direction within the portal system.
Easy-to-draw line diagram on altered direction of portal and systemic flow in case of cirrhosis.

Imaging Recommendation:

Routine surveillance for malignancy, usually with 6 monthly ultrasound, or earlier as per case scenario.

Top 3 Differential Diagnosis:

Summary on few top differential diagnosis for cirrhosis are as follows:

A summary providing key clues to differentiate cirrhosis from other top differential diagnoses. The summary outlines distinctive features and imaging findings essential for accurate diagnosis and differentiation in radiology.
Summarized clues to differentiate cirrhosis from other top differential diagnosis.

Clinical Features:

  • Symptoms –
A summarized list outlining common clinical manifestations observed in a patient with cirrhosis. The list provides key signs and symptoms often encountered in clinical practice, aiding in the recognition and diagnosis of cirrhosis.
Summarized list of common clinical manifestations in a patient with cirrhosis.
  • Age/Sex predilection: Variable
  • Risk factors: Hepatitis B,C,D infections, excessive Alcohol consumption, underlying pathologies like alpha antitrypsin deficiency. Refer Etiological Classification for summarized list.
A table categorizing types of cirrhosis based on their morphology and etiology. The table provides a structured overview of the different classifications of cirrhosis, delineating the various morphological features and underlying causes associated with each type.
Table of classifying types of cirrhosis based on their morphology and etiology.
A depiction of common scoring systems utilized to quantify the severity of cirrhosis. This image illustrates the various scales and criteria employed in clinical practice to assess and grade the extent of liver damage and dysfunction in patients with cirrhosis.
Common scoring systems used to quantify severity of cirrhosis.

Etymology and synonyms :

The Greek word ‘kirros’ means yellowish and tawny. Adding ‘osis’ a common medical suffix to it, formed the word Cirrhosis, first described in this way by French physician Laennec.

Treatment :

Summary of cirrhosis treatment options.
Summarized list of treatment actions in the case of cirrhosis.

References:

Single best review article:

Owen, C. and Meyers, P. (2006) ‘Sonographic evaluation of the portal and Hepatic Systems’, Journal of Diagnostic Medical Sonography, 22(5), pp. 317–328. doi:10.1177/8756479306293101.

Other references:

  • Maruyama, H. and Shiina, S. (2021) ‘Collaterals in portal hypertension: Anatomy and clinical relevance’, Quantitative Imaging in Medicine and Surgery, 11(8), pp. 3867–3881. doi:10.21037/qims-20-1328.
  • Huber A, Ebner L, Heverhagen JT, Christe A. State-of-the-art imaging of liver fibrosis and cirrhosis: A comprehensive review of current applications and future perspectives. Eur J Radiol Open. 2015 May 26;2:90-100. doi: 10.1016/j.ejro.2015.05.002. PMID: 26937441; PMCID: PMC4750581.
  • Hanna, R.F. et al. (2008) ‘Cirrhosis-associated hepatocellular nodules: Correlation of histopathologic and MR imaging features’, RadioGraphics, 28(3), pp. 747–769. doi:10.1148/rg.283055108.
  • S. H. I. Desoukey, et al. “Spectrum of Acquired Portal Vein Abnormalities in Cirrhotic Liver: Dynamic MRI Findings.” ECR 2020, European Society of Radiology. Educational exhibit.
  • Bandali, M.F. et al. (2017) ‘Portal hypertension: Imaging of portosystemic collateral pathways and associated image-guided therapy’, World Journal of Gastroenterology, 23(10), p. 1735. doi:10.3748/wjg.v23.i10.1735.
  • Leon A Adams, Max Bulsara, Enrico Rossi, Bastiaan DeBoer, David Speers, Jacob George, James Kench, Geoffrey Farrell, Geoffrey W McCaughan, Gary P Jeffrey, Hepascore: An Accurate Validated Predictor of Liver Fibrosis in Chronic Hepatitis C Infection, Clinical Chemistry, Volume 51, Issue 10, 1 October 2005, Pages 1867–1873, https://doi.org/10.1373/clinchem.2005.048389
  • Gupta, A.A. et al. (2004) ‘CT and MRI of cirrhosis and its mimics’, American Journal of Roentgenology, 183(6), pp. 1595–1601. doi:10.2214/ajr.183.6.01831595.
  • Iranpour P, Lall C, Houshyar R, Helmy M, Yang A, Choi JI, Ward G, Goodwin SC. Altered Doppler flow patterns in cirrhosis patients: an overview. Ultrasonography. 2016 Jan;35(1):3-12. doi: 10.14366/usg.15020. Epub 2015 May 27. PMID: 26169079; PMCID: PMC4701371.
  • Jo, P.C. et al. (2017) ‘Integration of contrast-enhanced us into a multimodality approach to imaging of nodules in a cirrhotic liver: How I do it’, Radiology, 282(2), pp. 317–331. doi:10.1148/radiol.2016151732.
  • Soresi M, Giannitrapani L, Cervello M, Licata A, Montalto G. Non invasive tools for the diagnosis of liver cirrhosis. World J Gastroenterol. 2014 Dec 28;20(48):18131-50. doi: 10.3748/wjg.v20.i48.18131. PMID: 25561782; PMCID: PMC4277952.
  • Moriyasu F, Nishida O, Ban N, Nakamura T, Sakai M, Miyake T, Uchino H. “Congestion index” of the portal vein. AJR Am J Roentgenol. 1986 Apr;146(4):735-9. doi: 10.2214/ajr.146.4.735. PMID: 3485345.
  • Junqueira, José Claudio Nogueira et al. “Patent paraumbilical vein on ultrasound: not always cirrhosis.” (2018).
  • Yoshiji H, Nagoshi S, Akahane T, Asaoka Y, Ueno Y, Ogawa K, Kawaguchi T, Kurosaki M, Sakaida I, Shimizu M, Taniai M, Terai S, Nishikawa H, Hiasa Y, Hidaka H, Miwa H, Chayama K, Enomoto N, Shimosegawa T, Takehara T, Koike K. Evidence-based clinical practice guidelines for Liver Cirrhosis 2020. J Gastroenterol. 2021 Jul;56(7):593-619. doi: 10.1007/s00535-021-01788-x. Epub 2021 Jul 7. PMID: 34231046; PMCID: PMC8280040.
  • Sharma B, John S. Hepatic Cirrhosis. [Updated 2022 Oct 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482419/

Case co-authored by TeamGyan Member  Dr. Bhargavi Sovani

Illustrations by Dr Bhargavi Sovani.

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