Cirrhosis & Portal Hypertension: Radiologic Findings

Transcription

1 March 2002 Cirrhosis & Portal Hypertension: Radiologic Findings Nazleen Bharmal Harvard Medical School Year III

2 Our Patient 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 Impression Alcoholic cirrhosis, Hepatic encephalopathy 2

3 Menu of Tests Ultrasound (US) Computed tomography (CT) Magnetic resonance imaging (MRI) Nuclear medicine 3

4 Our Patient: US Imaging Ultrasound of Liver Ascites Liver Doppler studies: patent portal & hepatic veins courtesy of BIDMC PACS 4

5 Differential Diagnosis: Hepatic Ascites* Sinusoidal Cirrhosis (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 5

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

7 CT Abdomen: Normal Patient 1 Liver Aorta Stomach Spleen CT Abdomen with IV contrast courtesy of BIDMC PACS 7

8 Our Patient: CT Imaging Falciform ligament? CT Abdomen with IV contrast Nodular Liver Stomach Ascites Spleen courtesy of BIDMC PACS 8

9 Our Patient: Diagnosis Liver Cirrhosis LIVER CIRRHOSIS Portal Hypertension Ascites, Varices, Splenomegaly, Encephalopathy Netter, F.H. The CIBA Collection of Medical Illustrations, Volume 3: Digestive System, Part III,

10 Portal Hypertension Signs & Symptoms Netter, F.H. The CIBA Collection of Medical Illustrations, Volume 3: Digestive System, Part III,

11 Portal System: Portacaval Anastomoses Netter, F.H. The CIBA Collection of Medical Illustrations, Volume 3: Digestive System, Part III,

12 Esophageal Varices Our Patient CT Abdomen with IV contrast courtesy of BIDMC PACS 12

13 Esophageal Varices: Another Look Normal Anatomy Abnormal Anatomy Netter, F.H. The CIBA Collection of Medical Illustrations, Volume 3: Digestive System, Part I,

14 Esophageal Varices: Barium Study Normal Abnormal d.harvard.edu/collec tion_display.asp?tas k=framer&tn=y&lo okupguid=head{0 193EB D1D-BE9E- 31E85A142F65} n_display.asp?task=fr amer&tn=y&lookup GUID=Head{33ACA E5C-C5E8-4D1F- A23F- 626B72EBF9DC} 14

15 Esophageal Varices: Endoscopy Normal Abnormal ML/GI121.hmtl 15

16 CT Abdomen: Normal Patient 1 Liver Aorta Stomach Spleen CT Abdomen with IV contrast courtesy of BIDMC PACS 16

17 Gastric Varices Our Patient CT Abdomen with IV contrast courtesy of BIDMC PACS 17

18 More Varices Spleen & Bowel Our Patient CT Abdomen with IV contrast courtesy of BIDMC PACS 18

19 Splenomegaly Patient 2 Patient 3 Anasarca Ascites CT Abdomen w/ IV contrast MR Abdomen T2 Coronal courtesy of BIDMC PACS 19

20 One More Finding Our Male Patient Gynecomastia Gynecomastia CT Abdomen without IV contrast courtesy of BIDMC PACS 20

21 Our Patient: Course High risk for UGIB and HCC Intractable Ascites TIPS procedure Liver Transplant 21

22 TIPS Procedure Our Patient Angiogram TIPS stent with contrast demonstrates flow from portal vein to IVC, thus bypassing the liver courtesy of BIDMC PACS 22

23 TIPS Procedure: US Imaging Our Patient Liver Ultrasound Ascites Liver Stent courtesy of BIDMC PACS 23

24 TIPS Procedure: Color Doppler US Liver Ultrasound Our Patient Patent TIPS Red = flow towards transducer Blue = flow away from transducer courtesy of BIDMC PACS 24

25 The TIPS procedure relieved the ascites somewhat. Our patient went on to receive a liver transplant. 25

26 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: , 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 Brown JJ, Naylor MJ, Yagan N. Imaging of Hepatic Cirrhosis. Radiology 202:1-13, Taylor HM, Ros PR. Hepatic Imaging. Radiologic Clinics of North America 36(2):237-44, March Portal Hypertension. The Merch Manual Section 4:Chapter 38, Merck & Co, Inc. New Jersey:

27 Acknowledgements Pamela Lepkowski Daniel Saurbour, MD Haldon Bryer, MD Ravi Thakur, MD Larry Barbaras and Cara Lyn D amour 27