Transcript Aucun titre de diapositive - EGYPTIAN FRENCH HEPATOLOGY

Imaging of cirrhosis
Valérie Vilgrain
Service de Radiologie
Hôpital Beaujon
France
Cirrhosis
Extensive fibrosis
and regenerative nodules
Main causes
alcohol ingestion
chronic hepatitis C
chronic hepatitis B
hemochromatosis
Wilson disease
Micronodular
Macronodular
nodules < 3 mm
larger nodules
Diagnosis
Liver diseases mimicking cirrhosis
Prognosis
Non invasive diagnosis of fibrosis
Diagnosis of cirrhosis
Nodularity of the liver surface
Nodular internal architecture
Changes of hepatic morphology
Vascular changes
Portal hypertension
Nodularity of the liver surface
Nodular internal architecture
Correlate with the gross appearance of cirrhosis
Surface
. Initially described with high frequency transducer
. Seen with US, CT and MR
Internal architecture
. Best seen with US and MR
. Regenerative nodules hypoechoic - hypointense
. Septa
hyperechoic - hyperintense
Dilelio, Radiology 1989
Cirrhosis
Surface nodularity
Di Lelio
Richard
Ferral
Ladenheim
Colli
Se
Sp
Accuracy
88
58
88
13
54
94
86
82
88
95
89
81
84
76
Radiology 1989
J. Radiol 1985
Gastrointest 1992
Radiology 1992
Radiology 2003
Hepatic morphologic changes
Hepatic morphologic changes
Quantitative results (1)
Caudate lobe
Caudate-right lobe ratio
Modified caudate-right lobe ratio
(> 0.65)
(> 0.90)
Harbin, Radiology 1980
Awaya, Radiology 2002
Hepatic morphologic changes
Quantitative results (2)
Segment 4
Control group 43 ± 8 mm
Cirrhosis
28 ± 9 mm
Cutoff: 30 mm
Limit: measurement obtained at US
Lafortune, Radiology 1998
Hepatic morphologic changes
Other signs
Expanded gallbladder fossa
Specificity and PPV of 98%
Associated with atrophy of the segment 4
Enlargment of hilar periportal space
Seen in 98% in early cirrhosis
Cutoff of 10 mm
. Control group: 5.3 mm
. Cirrhosis:
15.5 mm
Ito, Radiology 1999
Ito, JMRI 2000
Vascular changes
Hepatic veins
Normally triphasic
Cirrhosis
decreased diameter
altered waveform in 50%
correlated with the severity
reduced transit time (contrast US)
Bolondi, Radiology 1991
Colli, AJR 1994
Albrecht, Lancet 1999
Vascular changes
Hepatic artery
HA diastolic velocity > PV velocity
Increased HA diameter
Increased RI and PI of the hepatic artery
Portal vein velocity
Liver vascular index =
-------------------------Hepatic artery PI
< 12 cm/sec
Iwao, Am J Gastroenterol 1997
Portal hypertension
Increased pressure
Portocaval gradient
Portal hemodynamics
Collaterals
Ascites
Splenomegaly
> 15 mm Hg
> 5 mm Hg
Diagnosis of PHT
Splanchnic veins
Enlargment of splanchnic veins
Lack of caliber variations of SMV
Reversed flow
SMV
2.1%
splenic vein 3.1%
Alpern, Radiology 1987
Bolondi, Radiology 1982
Diagnosis of PHT
Diameter of the portal vein
> 13 mm Se
40%
> 15 mm Se 12.5%
Alterations of portal blood flow abs of end-diastolic
arterialized flow
bidirectional flow
reversed flow 1%
Bolondi, Radiology 1982
Vilgrain, Gastrointest Radiol 1990
Lafortune 1990
Gaiani, Gastroenterology 1991
Diagnosis of PHT
Left gastric vein
Diameter > 6 mm
Hepatofugal flow
26%
78%
Wachsberg, AJR 1994
Diagnosis of PHT
Gastroesophageal veins
Diagnosis of PHT
Paraumbilical vein
Diagnosis of PHT
Splenorenal veins
Diagnosis of PHT
Other collaterals
Retroperitoneal
veins
Omental veins
Rectal varices
Gallbladder varices
Diagnosis of PHT
Mean portal velocity
Mean portal blood flow
cm/sec
ml/min
controls
cirrhosis
controls
cirrhosis
Gaiani et al
19  2.1
11.4  3.7
919  285
1197  625
Moriyasu et al
15.3  4
9.7  2.6
899  284
870  289
Zoli et al
16  0.5
10.5  0.6
694  23
736  46
Ohnishi et al
17  3.9
12  3
648  186
690  258
Gaiani, Hepatology 1989
Moriyasu, AJR 1986
Zoli, J Ultrasound Med 1985
Ohnishi, Gastroenterology 1985
Cirrhosis
Ultrasound-Score
Accuracy
Surface nodularity
+ mean portal velocity
82%
Spleen length
+ mean portal velocity
84%
Spleen length
+mean portal velocity
+hepatic venous spectrum
89%
Gaiani, J Hepatol 1997
Aubé, J Hepatol 1999
Aubé, Eur J Gastroentrol 2004
Liver diseases mimicking cirrhosis
Common findings
Morphologic changes of the liver
May give signs of PHT
Generally vascular or biliary diseases
But
Rarely cause nodularity of the liver surface
Rarely have nodular regeneration
Primary sclerosing cholangitis
Lobular contour
Caudate hypertrophy
Lateral segment atrophy
Posterior segment atrophy
73%
98%
58%
36%
Dilated ducts
67%
End stage disease
Dodd, Radiology 1999
Congenital hepatic fibrosis
Mean age 39 years
Liver morphologic abnormalities
Splenomegaly
Varices
Renal abnormalities
Ductal plate malformation
89%
83%
78%
56%
50%
Zeitoun, Radiology 2004
Congenital hepatic fibrosis
Hypertrophy of the left lateral
Normal or hypertrophy of the segment 4
Atrophy of the right lobe
Zeitoun, Radiology 2004
Budd-Chiari disease
Hypertrophy of the caudate lobe > 50%
Lobar atrophy/hypertrophy
Abnormal hepatic veins
Hepatic venous collaterals
Portal cavernoma
Central vs peripheral zone
Vilgrain, Radiology 2006
Imaging in assessing prognosis?
Comparison between compensated and uncompensated
cirrhosis
Serial imaging
Stability and functional reserve
. Hypertrophy and increasing of the caudate lobe 1, 2, 3
. High caudate to right lobe ratio 1
. Increasing lateral segment 2
Clinical progression
. Progressive atrophy of the right lobe and medial segment 2
. Spleen enlargment 3
1. Watanabe, Dig Dis Sci 1999
. Varices 3
2. Ito, Radiology 1998
3. Ito, AJR 1997
Limitations of non invasive imaging
Most signs seen in advanced cirrhosis
No specific signs associated with fibrosis
=> Need to find other criteria
other imaging
Diagnosis of fibrosis
Blood tests: Fibrotest
Elastrography
Liver MR diffusion
Liver perfusion
Fibrotest
Alpha 2 macroglobulin
Haptoglobin
Apolipoprotein 1
Total bilirubin
GGT
ALT
0
- 0.10 Probability of fibrosis < 10%
0.10 - 0.60 Liver biopsy recommended
0.60 - 1.00 Probability of fibrosis > 90%
Imbert-Bismuth, Lancet 2001
Elastography (Fibroscan)
Ultrasound (5MHz) and low frequency
(50 Hz) elastic waves
Propagation velocity is related to elasticity
Liver MR diffusion
Reduced ADC in cirrhosis
Taouli, Radiology 2003
Liver perfusion
Van Beers, AJR 2001
CONCLUSION
Today, non invasive imaging is crucial
for diagnosing cirrhosis and its
complications.
Tomorrow, the challenge of imaging will
be to detect early stages of fibrosis and
cirrhosis and to demonstrate therapeutic
response.