Diagnostic Ultrasound - Abdomen and Pelvis

Venoocclusive Disease
Diagnoses: Liver
– No adverse effects of liver disease, and
– No medications required for diuresis or hepatic pain,
and
– All symptoms, signs, and laboratory features
reversible
○ Moderate disease (most common form of VOD)
– Adverse effects of liver disease present, and
– Sodium restriction or diuresis required, or
– Medication for hepatic pain required, and
– All symptoms, signs, and laboratory features
reversible
○ Severe disease
– Adverse effects of liver disease present, and
– Symptoms, signs, or laboratory features not resolved
within 100 days of transplantation, or
– Death
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Painful hepatomegaly, jaundice, peripheral edema,
unexplained weight gain
○ Elevation of liver function tests
• Other signs/symptoms
○ Signs and symptoms of liver failure such as ascites,
encephalopathy, etc.
Demographics
• Gender
○ Women affected more than men
• Risk factors
○ Preexisting liver disease
○ Specific types of conditioning therapy prior to
transplantation
○ Mismatched source of hematopoietic cells or marrow
○ Use of specific antibiotics during transplantation
Natural History & Prognosis
• Clinical and laboratory features of VOD usually begin within
3 weeks of transplantation
• Occurs most frequently following hematopoietic cell
transplantation
○ Affects 50-80% of marrow transplant, stem cell, or
umbilical cord blood recipients
○ Responsible for 5-15% of deaths in population with VOD
○ Fatality rate as high as 30% in VOD associated with
hematopoietic cell transplantation
○ Severe VOD seen in 15% of patients withhematopoietic
cell transplantation
• Prognosis depends on extent of hepatic injury and
dysfunctions
• VOD may occasionally be seen in setting of pyrrolizidine
alkaloid ingestion in form of teas
Treatment
• Antithrombotic and thrombolytic medication
• Diuretics and sodium restriction
• Analgesia for right upper quadrant pain control
DIAGNOSTIC CHECKLIST
Consider
• Clinical history of recent prior hematopoietic or stem cell
transplantation and high dose chemotherapy helpful in
diagnosis
• Imaging can only suggest VOD;diagnosis based on clinical
criteria ± biopsy
• Liver biopsy is usually diagnostic but is often hazardous due
to coexisting coagulopathy
• Clinical diagnosis (modified Seattle criteria)
○ At least 2 of the following occurring within 20 days of
transplantation
– Serum bilirubin > 34 μmol/L (> 2mg/dL)
– Hepatomegaly with right upper quadrant pain
– > 2% weight gain from baseline due to fluid retention
Image Interpretation Pearls
• Ultrasound is imaging modality of choice
• Doppler evaluation of hepatic vessels critical in appropriate
diagnosis
SELECTED REFERENCES
1. Kambham N et al: Hematopoietic stem cell transplantation: graft versus host
disease and pathology of gastrointestinal tract, liver, and lung. Adv Anat
Pathol. 21(5):301-20, 2014
2. Zhou H et al: Hepatic sinusoidal obstruction syndrome caused by herbal
medicine: CT and MRI features. Korean J Radiol. 15(2):218-25, 2014
3. Mahgerefteh SY et al: Radiologic imaging and intervention for
gastrointestinal and hepatic complications of hematopoietic stem cell
transplantation. Radiology. 258(3):660-71, 2011
4. Coppell JA et al: Hepatic veno-occlusive disease following stem cell
transplantation: incidence, clinical course, and outcome. Biol Blood Marrow
Transplant. 16(2):157-68, 2010
5. Rubbia-Brandt L: Sinusoidal obstruction syndrome. Clin Liver Dis. 14(4):651-
68, 2010
6. Chung YE et al: Electronic clinical challenges and images in GI. Hepatic
venoocclusive disease. Gastroenterology. 135(1):e3-4, 2008
7. Erturk SM et al: CT features of hepatic venoocclusive disease and hepatic
graft-versus-host disease in patients after hematopoietic stem cell
transplantation. AJR Am J Roentgenol. 186(6):1497-501, 2006
8. Lassau N et al: Prognostic value of doppler-ultrasonography in hepatic venoocclusive
disease. Transplantation. 74(1):60-6, 2002
9. McCarville MB et al: Hepatic veno-occlusive disease in children undergoing
bone-marrow transplantation: usefulness of sonographic findings. Pediatr
Radiol. 31(2):102-5, 2001
10. van den Bosch MA et al: MR imaging findings in two patients with hepatic
veno-occlusive disease following bone marrow transplantation. Eur Radiol.
10(8):1290-3, 2000
11. Lassau N et al: Hepatic veno-occlusive disease after myeloablative treatment
and bone marrow transplantation: value of gray-scale and Doppler US in 100
patients. Radiology. 204(2):545-52, 1997
12. McDonald GB et al: Veno-occlusive disease of the liver and multiorgan failure
after bone marrow transplantation: a cohort study of 355 patients. Ann
Intern Med. 118(4):255-67, 1993
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