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.