Diagnostic Ultrasound - Abdomen and Pelvis

Hepatic Cirrhosis
184
Diagnoses: Liver
Hepatic Sarcoidosis
• Hypoattenuating nodules (size: Up to 2 cm)
• Hypointense nodules on T1- and T2WI MR
PATHOLOGY
General Features
• Etiology
○ Alcohol abuse is most common cause in West (1 of 10
leading causes of death [6th in USA]); hepatitis B in Asia
– USA: Alcohol (60-70%), chronic viral hepatitis B/C
(10%)
○ Primary biliary cirrhosis (5%), hemochromatosis (5%)
○ Primary sclerosing cholangitis, drugs, cardiac causes
○ In children: Biliary atresia, hepatitis, α-1 antitrypsin
deficiency
• Micronodular (Laennec) cirrhosis: Alcohol
• Macronodular (postnecrotic) cirrhosis: Viral
• Catalase oxidation of ethanol → damage cellular
membranes & proteins
• Steatosis → hepatitis → cirrhosis
• Regenerative (especially siderotic) nodules → dysplastic
nodules → HCC
○ Dysplastic nodules considered premalignant
Staging, Grading, & Classification
• Based on morphology, histopathology, and etiology
○ Micronodular (Laennec) cirrhosis (< 1 cm diameter):
Alcoholism (60-70% cases in USA)
○ Macronodular (postnecrotic) cirrhosis: Viral hepatitis
(10% of cases in USA; majority of cases worldwide)
Gross Pathologic & Surgical Features
• Alcoholic cirrhosis
○ Early stage: Large, yellow, fatty, micronodular liver
○ Late stage: Shrunken, brown-yellow, hard organ with
macronodules
• Postnecrotic cirrhosis
○ Macronodular (> 3 mm to 1 cm); fibrous scars
Microscopic Features
• Portal-central, portal-portal fibrous bands
• Micro- & macronodules; mononuclear cells
• Abnormal arteriovenous interconnections
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Alcoholic cirrhosis: May be clinically silent
○ Nodular liver, anorexia, malnutrition, weight loss
○ Portal hypertension: Splenomegaly, varices, caput
medusae
○ Fatigue, jaundice, ascites, encephalopathy
○ Gynecomastia: Liver unable to metabolize estrogens
• Clinical profile
○ Patient with history of alcoholism, nodular liver, jaundice,
ascites, and splenomegaly
• Lab data: Abnormal liver function tests; anemia
○ Alcoholic cirrhosis: Severe increase in AST (SGOT)
○ Viral: Severe increase in ALT (SGPT)
Demographics
• Epidemiology
○ Middle age and elderly; males > females
○ 3rd leading cause of death for men 34-54 years
○ Risk of HCC
– USA: Hepatitis C (cirrhosis) causes 30-50% of HCC
cases
– Japan: Hepatitis C (cirrhosis) causes 70% of HCC cases
○ Mortality due to complication
– Ascites (50%), variceal bleeding (25%), renal failure
(10%), bacterial peritonitis (5%), complications of
ascites therapy (10%)
Natural History & Prognosis
• Complications
○ Ascites, variceal hemorrhage, renal failure, coma
○ HCC: Due to hepatitis B & C, alcoholism
• Prognosis
○ Alcoholic cirrhosis: 5-year survival < 50%
○ Advanced disease: Poor prognosis
• Liver fibrosis staging
○ Determines prognosis and management
○ Liver biopsy is current reference standard
– Metavir scoring system is specific to hepatitis C;
provides grade and stage
□ Grade (activity or inflammation) A0 = no activity to
A3 = severe
□ Stage (fibrosis) F0 = no fibrosis to F4 = cirrhosis
○ Emerging noninvasive techniques to quantify liver
fibrosis
– Ultrasound: Transient elastography and shear wave
elastography
– Magnetic resonance elastography (MRE)
Treatment
• Alcoholic cirrhosis
○ Abstinence; decreased protein diet; multivitamins
○ Prednisone; diuretics (for ascites)
• Management limited to treating complications &
underlying cause
• Advanced stage: Liver transplantation
DIAGNOSTIC CHECKLIST
Consider
• Rule out other causes of nodular dysmorphic liver
Image Interpretation Pearls
• Nodular liver contour; lobar atrophy & hypertrophy
• Regenerative nodules, ascites, splenomegaly, varices
SELECTED REFERENCES
1. Beland MD et al: A pilot study estimating liver fibrosis with ultrasound shearwave
elastography: does the cause of liver disease or location of
measurement affect performance? AJR Am J Roentgenol. 203(3):W267-73,
2014
2. Ferraioli G et al: Shear wave elastography for evaluation of liver fibrosis. J
Ultrasound Med. 33(2):197-203, 2014
3. Buadu A et al: Small liver nodule detection with a high-frequency transducer
in patients with chronic liver disease: report of 3 cases. J Ultrasound Med.
32(2):355-9, 2013
4. Irshad A et al: Current role of ultrasound in chronic liver disease: surveillance,
diagnosis and management of hepatic neoplasms. Curr Probl Diagn Radiol.
41(2):43-51, 2012
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