Cirrhosis & Portal Hypertension: Radiologic Findings

Nazleen Bharmal

Gillian Lieberman, MD

Nazleen

BharmalHarvard Medical School Year III

Gillian Lieberman, MD

March 2002

Cirrhosis & Portal Hypertension: Radiologic Findings

2

Nazleen Bharmal

Gillian Lieberman, MD

•

HPI –

50 year-old male presents with confusion

•

PMH –

alcoholism, s/p

cholecystectomy

•

PE –

jaundice, positive abdominal fluid wave

•

Labs –

Abnormal LFTs: nl

aminotransferases, ↑

TBili, ↑

PT, ↓

Alb, ↑

Ammonia, ↑

Alk

Phos

Our Patient

•

Impression –

Alcoholic cirrhosis, Hepatic encephalopathy

3

Nazleen Bharmal

Gillian Lieberman, MD

Menu of Tests•

Ultrasound (US)

•

Computed tomography (CT)

•

Magnetic resonance imaging (MRI)

•

Nuclear medicine

4

Nazleen Bharmal

Gillian Lieberman, MD

courtesy of BIDMC PACS

Ultrasound of Liver

Ascites

Liver

Our Patient: US Imaging

Doppler studies: patent portal & hepatic veins

5

Nazleen Bharmal

Gillian Lieberman, MD

Differential Diagnosis: Hepatic Ascites*

SinusoidalCirrhosis (81%)

SBP

Hepatitis

Liver Metastases

HCC

Post-Sinusoidal• Constrictive pericarditis

• Right-sided CHF

• Tricuspid insufficiency

• Budd-Chiari

syndrome

• Veno-occlusive disease

Pre-Sinusoidal•

Portal or Splenic vein thrombosis

• Schistosomiasis

* Portal Hypertension-Related Etiologies

6

Nazleen Bharmal

Gillian Lieberman, MD

Hepatic Anatomy

Sullivan, Lisa. The Liver, Biliary System, and Pancreas. Juhl: Paul and Juhl's Essentials of Radiologic Imaging, 7th ed., Lippincott Williams & Wilkins, 1998.

7

Nazleen Bharmal

Gillian Lieberman, MD

CT Abdomen with IV contrast courtesy of BIDMC PACS

CT Abdomen: NormalPatient 1

Aorta

Liver Stomach

Spleen

8

Nazleen Bharmal

Gillian Lieberman, MD

courtesy of BIDMC PACS

CT Abdomen with IV contrast

Stomach

SpleenAscites

Nodular Liver

Our Patient: CT Imaging

?Falciform

ligament

9

Nazleen Bharmal

Gillian Lieberman, MD

Our Patient: Diagnosis

Netter, F.H. The CIBA Collection of Medical Illustrations, Volume 3: Digestive System, Part III, 1957

Liver Cirrhosis

Portal Hypertension

Ascites, Varices, Splenomegaly, Encephalopathy

LIVER CIRRHOSIS

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Nazleen Bharmal

Gillian Lieberman, MD

Netter, F.H. The CIBA Collection of Medical Illustrations, Volume 3: Digestive System, Part III, 1957

Portal Hypertension Signs & Symptoms

11

Nazleen Bharmal

Gillian Lieberman, MD

Netter, F.H. The CIBA Collection of Medical Illustrations, Volume 3: Digestive System, Part III, 1957

Portal System: Portacaval

Anastomoses

12

Nazleen Bharmal

Gillian Lieberman, MD

CT Abdomen with IV contrast courtesy of BIDMC PACS

Our Patient

Esophageal Varices

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Nazleen Bharmal

Gillian Lieberman, MD

Esophageal Varices: Another Look

Netter, F.H. The CIBA Collection of Medical Illustrations, Volume 3: Digestive System, Part I, 1957

Normal Anatomy

Abnormal Anatomy

14

Nazleen Bharmal

Gillian Lieberman, MD

Esophageal Varices: Barium Study

http://mycourses.me

d.harvard.edu/collec

tion_display.asp?tas

k=framer&tn=y&lo

okupGUID=Head{0

193EB25-8547-

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.harvard.edu/collectio

n_display.asp?task=fr

amer&tn=y&lookup

GUID=Head{33ACA

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Normal Abnormal

15

Nazleen Bharmal

Gillian Lieberman, MD

Esophageal Varices: Endoscopy

http://medlib.med.utah.edu/WebPath/GIHT

ML/GI121.hmtl http://home.t-online.de/home/afreytag/o06e.htm

Normal Abnormal

16

Nazleen Bharmal

Gillian Lieberman, MD

CT Abdomen with IV contrast courtesy of BIDMC PACS

CT Abdomen: NormalPatient 1

Aorta

Liver Stomach

Spleen

17

Nazleen Bharmal

Gillian Lieberman, MD

CT Abdomen with IV contrast courtesy of BIDMC PACS

Our PatientGastric Varices

18

Nazleen Bharmal

Gillian Lieberman, MD

CT Abdomen with IV contrast courtesy of BIDMC PACS

Our PatientMore Varices

–

Spleen & Bowel

19

Nazleen Bharmal

Gillian Lieberman, MD

courtesy of BIDMC PACS

Patient 2

SplenomegalyPatient 3

Ascites

CT Abdomen w/ IV contrast

Anasarca

MR Abdomen T2 Coronal

Ascites

20

Nazleen Bharmal

Gillian Lieberman, MD

CT Abdomen without IV contrast courtesy of BIDMC PACS

One More Finding…Our Male Patient

Gynecomastia Gynecomastia

21

Nazleen Bharmal

Gillian Lieberman, MD

Our Patient: Course

• High risk for UGIB and HCC

•Intractable Ascites

–

TIPS procedure

• Liver Transplant

22

Nazleen Bharmal

Gillian Lieberman, MD

courtesy of BIDMC PACS

TIPS ProcedureOur Patient

TIPS stent with contrast demonstrates flow from portal vein to IVC, thus bypassing the liver

Angiogram

23

Nazleen Bharmal

Gillian Lieberman, MD

courtesy of BIDMC PACS

TIPS Procedure: US Imaging

Liver Ultrasound

Liver

Stent

Our Patient

Ascites

24

Nazleen Bharmal

Gillian Lieberman, MD

courtesy of BIDMC PACS

TIPS Procedure: Color Doppler US

Liver UltrasoundOur Patient

• Patent TIPS

•

Red = flow towards transducer

•

Blue = flow away from transducer

25

Nazleen Bharmal

Gillian Lieberman, MD

The TIPS procedure relieved the ascites

somewhat. Our patient

went on to receive a liver transplant.

26

Nazleen Bharmal

Gillian Lieberman, MD

References•

Netter, F.H. The CIBA Collection of Medical Illustrations, Volume 3: Digestive System, Part III. CIBA-Geigy, Summit, 1957

•

Netter, F.H. The CIBA Collection of Medical Illustrations, Volume 3: Digestive System, Part I. CIBA-Geigy, Summit, 1957

•

Sabatine, Marc S., MD editor. Pocket Medicine. Lippincott Williams & Wilkins. Philadelphia: 2000. 3-20, 3-22.

• Gamuts, Radiology Texts, UptoDateonline

•

Sullivan, Lisa. The Liver, Biliary System, and Pancreas. Juhl: Paul and Juhl's Essentials of Radiologic Imaging, 7th ed., Lippincott Williams & Wilkins, 1998, pgs 511-514.

• Brown JJ, Naylor MJ, Yagan

N. Imaging of Hepatic Cirrhosis. Radiology 202:1-13, 1997.

•

Taylor HM, Ros

PR. Hepatic Imaging. Radiologic Clinics of North America 36(2):237-44, March 1998.

•

Portal Hypertension. The Merch Manual Section 4:Chapter 38, Merck & Co, Inc. New Jersey:2001

27

Nazleen Bharmal

Gillian Lieberman, MD

Acknowledgements• Pamela Lepkowski

• Gillian Lieberman, MD

• Daniel Saurbour, MD

• Haldon

Bryer, MD

• Ravi Thakur, MD• Larry Barbaras and Cara Lyn D’amour