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Hasil Penelitian : Sonografi Sirosis Hepatis di RSUD Dr. Moewardi

Suyono, Sofiana, Heru, Novianto, Riza, Musrifah (Bagian Radiologi Fakultas Kedokteran

Universitas Sebelas MaretRu!ah Sakit U!u! "aerah "r# Moe$ardi Surakarta%# &er!in

"unia Kedokteran , No# '), *))+

PENDAHULUAN

Penyakit hepar terutama hepatitis yang disebabkan oleh virus terutama virus hepatitis !" saat inisedang melanda dunia baik di negara ma#u maupun negara berkembang. Mun$ulnya virus baruyaitu virus Hepatitis % menimbulkan hepatitis akut yang sporadik terutama pada usia dewasa&'(". Sirosis hepatis sebagian besar disebabkan oleh hepatitis )" penderitanya #uga tidak pernah

berkurang terutama dari pengamatan di RSDM Surakarta se#ak tahun*'')+ *'',.

SIROSIS HEPATIS

Definisi

Sirosis Hepatis adalah penyakit hati menahun difus ditandai dengan adanya pembentukan #aringan ikat disertai nodul *".

Etiologi

Penyebab yang pasti sampai sekarang belum #elas- di antaranya :

• aktor kekurangan nutrisi

• Hepatitis virus

• /at hepatotoksik

• Penyakit 0ilson

• Hemokromatosis.

Gejala klinis

1e#ala dini samar dan nonspesifik berupa kelelahan2 anoreksia2 dispepsia2 flatulen2 konstipasiatau diare2 berat badan berkurang2 nyeri tumpul atau berat pada epigastrium atau kuadran kananatas )". Manifestasi utama dan lan#ut sirosis merupakan akibat dari dua tipe gangguan fisiologis :

a. 1agal sel hati.

• 3kterus


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• %dema Perifer

• 4e$enderungan pendarahan

• %ritema palmaris telapak tangan merah"

• 5ngioma laba+laba

• etor hepatikum

• %nsefalopati hepatik

b. Hipertensi portal.

•

Splenomegali

• 6arises oesofagus dan lambung

• Manifestasi sirkulasi kolateral lain

Sedang asites dapat dianggap sebagai manifestasi gagal hepatoseluler dan hipertensi poratl )".

PEMERIKSAAN PENUNJANG

Pemeiksaan La!oatoi"m

7idak ada pemeriksaan u#i biokimia hati yang dapat men#adi pegangan dalam menegakkandiagnosis sirosis hepatis :

). Darah2 5nemia normokrom normositer2 hipokrom normositer2 hipokrom mikrositer atauhipokrom makrositer.

*. 4enaikan kadar en8im transaminase S197S1P7" *"

,. 5lbumin dan globulin serum2 Perubahan fraksi protein yang paling sering ter#adi pada penyakit hati adalah penurunan kadar albumin dan kenaikan kadar globulin akibat

peningkatan globulin gamma *".

;. Penurunan kadar . Peningkatan kadar gula darah


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Patient with $irrhosis showing tortuous hepati$ arteries in

addition to enlarged left lobe and $audate


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5nother sign of $irrhosis2 the e?panded gallbladder fossa sign as depi$ted in the image below2has been des$ribed on MR3 e?amination2 based on an evaluation by 3to and $oauthors of )' patients with $irrhosis and of )*, $ontrol patients.F>G 7he authorsA $riterion was enlargement of the peri$hole$ysti$ spa$e ie2 gallbladder fossa"@whi$h had to be demar$ated laterally by the edgeof the right hepati$ lobe2 medially by the edge of the lateral segment of the left hepati$ lobe2 or

posteriorly by the anterior edge of the $audate lobe@in $on#un$tion with nonvisuali8ation of themedial segment of the left hepati$ lobe on the same a?ial image. 7his a$hieved a sensitivity2spe$ifi$ity2 a$$ura$y2 and positive predi$tive value for the MR3 diagnosis of $irrhosis of &I(2I(2 I'(2 and I(2 respe$tively.

7he e?panded gallbladder fossa sign has a limited sensitivity&I(" in $irrhosis but is highly spe$ifi$ 7he authors des$ribed an enlarged2 peri$hole$ysti$2 fat+filled spa$e that often $ontains $ollaterals note the patent paraumbili$al vein FarrowG"2 with novisuali8ation of the medial segment of the left lobe of the liver at the level of the gallbladderfossa.

9n ultrasonographi$ e?amination2 the liver $ontour may appear nodular2 as in the first image below2 although Eadenheim and $olleagues have Buestioned the spe$ifi$ity of this sign. Similar$ontour deformities2 depi$ted in the se$ond image below2 are evident on e?amination by


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bran$hes are tortuous2 with a C$orks$rewC $onfiguration. Patientwith $irrhosis showing tortuous hepati$ arteries in addition to enlarged left lobe and $audate ' $mse$.

Dual+phase


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Marshak2 4arahan2 and $oauthors reported a higher freBuen$y in the alteration in the thi$kness of the wall of the 13 tra$t2 depi$ted below2 in patients with $irrhosis than in $ontrols &;( vs >(".FI2G

Se$ondary manifestations of $irrhosis in$lude thi$kening andedema of the small and large bowel2 as well as of the gallbladder wall2 whi$h is more $ommon inthe setting of as$ites and hypoproteinemia. 5 thi$kened small bowel is demonstrated here in a

=)+year+old patient who has $irrhosis with marked as$ites.


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and irregular in its e?ternal $ontour. %?trahepati$ manifestation of $irrhosis.Mesenteri$ edema and stranding is identified open arrow". Jote marked splenomegaly." Same patient: 5 $omputed tomography


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Splenomegaly with longitudinal dimensions of )*.= $m in a patient with portal hypertension and splenorenal shunt

6ari$es are not found where the portal vein pressure indire$tly measured as the hepati$ vein pressure gradient FH6P1G" is less than )* mm Hg. However2 not all patients with elevated portal pressures develop vari$eal bleeding. Joninvasive diagnosti$ imaging methods2 su$h as $olorflow Doppler US2 $ontrast+enhan$ed


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tra$ed to the umbili$us and its anastomosis with systemi$2 superfi$ial abdominal wall vessels in

image below. Portal venousphase $omputed tomography


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Jote also the prominent superfi$ial veins in the abdominal wall.Same patient as in the previous image2 se$tion more $audal. 7he image shows a very large vari?

in the umbili$al region $lini$ally evident as a $aput medusa".

Splenorenal shunt. 7his $olor flow Doppler ultrasonogram demonstrates $ollateral in the perispleni$ region open arrow"2 with simultaneous flow in the left renal vein $losed arrow".


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as in the previous image". 5 more advan$ed e?ample of a spontaneoussplenorenal shunt2 in a patient with al$ohol+related $irrhosis. Upper figure: 5 large2 dilated$ollateral vessel is present anterior to spleen arrow". Eower figure:


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7hree+dimensional reformat of a $omputed tomography


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7hree+dimensional reformat of a $omputed tomography


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Multifo$al hepato$ellular $ar$inoma in an elderly patient with$irrhosis who is presenting with fever. 7he arterial+phase image demonstrates regions of

hypervas$ularity in both lobes of the liver2 that do not persist into the portal venousphase

images. 7he portal vein is not o$$luded. 5s$ites is present.S$reening for hepato$ellular $ar$inoma. 5 real+time limited ultrasonogram shows aninhomogeneous liver. Jo masses were appre$iated.


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However2 with the rapid in$rease in right lobe liver donation surgery2 the pathologi$ $orrelationshould be e?$ellent be$ause the entire e?planted liver will be available.

Limitations of te&'ni("es

Real+time US is used e?tensively for s$reening2 but biopsy or additional imaging modalities arereBuired for $onfirmation. US is a nonspe$ifi$ test and identifies many nodules2 ranging fromregenerative nodules2 dysplasti$ nodules2 and fo$al fat to benign neoplasms2 su$h ashemangioma2 many of whi$h have no uniBuely dis$riminating features on US.

!e$ause these o$$ur with signifi$ant freBuen$y2 they pose a diagnosti$ $hallenge. or e?ample2in a study of s$reened patients with $irrhosis2 the authors dis$overed that although $ombinedassessment with US and 5P was a$$urate in identifying patients with H


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9f those patients with $irrhosis and vari$es2 *=+;'( e?perien$e bleeding. 7he management of portal hypertension and upper tra$t 13 bleeding has been revolutioni8ed by endos$opi$ andangiographi$ treatment. 7he use of the intravas$ularly pla$ed trans#ugular intrahepati$ portosystemi$ shunt 73PS" has provided a se$ond+line therapy for the management of portalhypertension2 with redu$ed mortality and morbidity $ompared with that asso$iated with the open

surgi$al pro$edure.

is$her2 4imura2 and $oauthors have used noninvasive modalities2 su$h as Doppler US2 portrayed below2 to monitor shunt paten$y with a reasonably high a$$ura$y of greater than'(".F)2 *'G 9$$asionally2 however2 $onventional Doppler te$hniBues fail to image signals. 7hus2enhan$ement by US $ontrast agents appears promising in improving visuali8ation2 as shown below.

7rans#ugular intrahepati$ portosystemi$ shunt 73PS" therapy for

the treatment of refra$tory as$ites- a ;I+year+old male with intra$table as$ites and re$urrent

pleural effusion from a pleuroperitoneal fistula see 3mages ;'+;)". 5 73PS pro$edure was

performed. 5 follow+up $omputed tomography

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