Diagnostic Ultrasound - Abdomen and Pelvis

Acute Hepatitis
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Diagnoses: Liver
• Lymphoma more common in immune-suppressed patients
Steatosis (Fatty Liver)
• Hepatomegaly
• Diffuse, patchy or focal increase in echogenicity
• Normal vessels course through "lesion"
PATHOLOGY
General Features
• Etiology
○ Viral hepatitis: Caused by 1 of 5 viral agents
– Hepatitis A (HAV), B (HBV), C (HCV), D (HDV), E (HEV)
viruses
○ Other causes of hepatitis
– Alcohol abuse
– Autoimmune reactions
– Metabolic disturbances
– Drug-induced injury
– Exposure to environmental agents
– Radiation therapy
• Different stages of hepatitis
○ Cellular dysfunction, necrosis, fibrosis, cirrhosis
• HBV: Sensitized cytotoxic T cells →hepatocyte necrosis →
tissue damage
• Alcoholic hepatitis: Inflammatory reaction leads to acute
liver cell necrosis
Staging, Grading, & Classification
• Acute hepatitis
○ Often self-limiting
• Chronic hepatitis
○ Fibrosis and cirrhosis develop in 20% HCV and 10% HBV
• Staging liver fibrosis
○ Liver biopsy
– Current gold standard to stage fibrosis
○ Shear-wave ultrasound and magnetic resonance
elastography
– Emerging noninvasive means of evaluating liver
fibrosis
Gross Pathologic & Surgical Features
• Acute viral hepatitis: Enlarged liver + tense capsule
• Chronic fulminant hepatitis: Atrophic liver
• Alcoholic steatohepatitis: Enlarged, yellow, greasy liver
Microscopic Features
• Acute viral: Coagulative necrosis with ↑ eosinophilia
• Chronic viral: Lymphocytes, macrophages, plasma cells, or
piecemeal necrosis
• Alcoholic hepatitis: Neutrophils/necrosis/Mallory bodies
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Acute hepatitis
– Acute HAV: > 80% present with malaise, anorexia,
fever, pain, hepatomegaly, or jaundice
– Acute HCV: 75% asymptomatic at time of infection
□ Fatigue, right upper quadrant pain in 25%
• Clinical profile
http://radiologyebook.com/
○ Teenage or middle-aged patient with history of fever,
RUQ pain, hepatomegaly, and jaundice
• Lab data: ↑ serologic markers; ↑ liver function tests
• Diagnosis based on
○ Serologic markers; virological and clinical findings
Demographics
• Age
○ Any age group (particularly teen-/middle-age)
• Gender
○ M = F
• Epidemiology
○ Viral hepatitis in USA
– HAV, HBC, and HCV account for 40%, 30%, and < 5%
of acute viral hepatitis, respectively
– HCV most common bloodborne infection in USA
□ Leading cause of HCC and liver transplant
Natural History & Prognosis
• Hepatitis can be self-limited or progressive and chronic in
nature
○ Chronic HCV infection: Occurs in 60-85%
○ Chronic HBV infection: Occurs in < 10% over age 5, 50%
of children, 90% of neonates
– HBV accounts for 15% of chronic viral hepatitis in USA
• Complications
○ Relapsing and fulminant hepatitis
○ Chronic viral (HBV, HCV) and alcoholic hepatitis
– Cirrhosis: 10% of HBV and 20% of HCV
– HCC: Particularly among carriers of HBsAg
• Prognosis
○ Acute viral and alcoholic: Good
○ Chronic persistent hepatitis: Good
○ Chronic active hepatitis: Not predictable
○ Fulminant hepatitis: Poor
Treatment
• Acute viral hepatitis (HAV): Supportive care; IG within 2
weeks of exposure, HBIG, vaccine
• Chronic HCV: Directly acting antiviral agents (DAAs)
○ Ledipasvir and sofosbuvir
○ Paritaprevir, ritonavir, ombitasvir, dasabuvir, ribavirin
○ Sofosbuvir and simeprevir, ±ribavirin
• Alcoholic hepatitis: Alcohol cessation and good diet
SELECTED REFERENCES
1. Firneisz G: Non-alcoholic fatty liver disease and type 2 diabetes mellitus: the
liver disease of our age? World J Gastroenterol. 20(27):9072-89, 2014
2. Heller MT et al: The role of ultrasonography in the evaluation of diffuse liver
disease. Radiol Clin North Am. 52(6):1163-75, 2014
3. Sudhamsu KC: Ultrasound findings in acute viral hepatitis. Kathmandu Univ
Med J (KUMJ). 4(4):415-8, 2006
4. Cakir B et al: Unusual MDCT and sonography findings in fulminant hepatic
failure resulting from hepatitis A infection. AJR Am J Roentgenol.
185(4):1033-5, 2005
5. Rubens DJ: Hepatobiliary imaging and its pitfalls. Radiol Clin North Am.
42(2):257-78, 2004
6. Han SH et al: Duplex Doppler ultrasound of the hepatic artery in patients
with acute alcoholic hepatitis. J Clin Gastroenterol. 34(5):573-7, 2002