Cirrhosis other imaging findings: Difference between revisions

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{{Cirrhosis}}
{{Cirrhosis}}
{{CMG}} {{AE}} {{ADI}} {{Cherry}}


{{CMG}}; {{AE}} {{ADI}}
==Overview==
==Overview==
[[Tc-99m]] labeled sulfur may be used in nuclear imaging to provide some indication of [[Liver|hepatic]] function in cirrhotic patients. In candidates for [[liver transplant]], [[CTA]] is used to asses the drainage of the [[liver]]. All patients with cirrhosis must undergo a diagnostic [[endoscopy]] for the evaluation of [[varices]]. [[Stomach|Gastric]] [[endoscopy]] is an option if [[gastric varices]] are suspected, and [[endoscopic ultrasound]] may also help in the visualization of [[varices]].  [[ERCP]] is performed if a [[Bile duct|biliary]] pathology such as [[primary sclerosing cholangitis]] is suspected as the underlying cause of cirrhosis.
==Other Imaging Findings==
==Other Imaging Findings==
===Nuclear Imaging===
===Nuclear Imaging===
====Tc-99m====
*[[Radionuclide]] testing may be useful in  the diagnosis of cirrhosis:<ref name="pmid26494949">{{cite journal |vauthors=Nishikawa H, Osaki Y |title=Liver Cirrhosis: Evaluation, Nutritional Status, and Prognosis |journal=Mediators Inflamm. |volume=2015 |issue= |pages=872152 |year=2015 |pmid=26494949 |pmc=4606163 |doi=10.1155/2015/872152 |url=}}</ref><ref name="pmid3995244">{{cite journal |vauthors=McLaren MI, Fleming JS, Walmsley BH, Ackery DM, Taylor I, Karran SJ |title=Dynamic liver scanning in cirrhosis |journal=Br J Surg |volume=72 |issue=5 |pages=394–6 |year=1985 |pmid=3995244 |doi= |url=}}</ref>
Tc-99m labeled sulfur used for functional imaging techniques provides some indication of hepatic function.  The labeled colloidal compound is taken up by [[reticuloepithelial]] cells, and it is the colloidal shift to the other organs (bone marrow, spleen) containing reticuloepithelial cells that provides evidence of portal hypertension. <ref>{{cite journal |author=Kim YS, Cho SW, Lee KJ, ''et al.'' |title=Tc-99m MIBI SPECT is useful for noninvasively predicting the presence of MDR1 gene-encoded P-glycoprotein in patients with hepatocellular carcinoma |journal=Clin Nucl Med |volume=24 |issue=11 |pages=874–9 |year=1999 |month=November |pmid=10551471 |doi= |url=}}</ref>
**[[Tc-99m]] labeled sulfur used for [[Functional imaging|functional imaging techniques]] provides some indication of [[Liver|hepatic]] function
** 99mTc sulfur [[colloid]] is normally taken up by cells of the [[reticuloendothelial system]]
**Cirrhosis: heterogeneity in the uptake of [[Technetium-99m|99mTc sulfur colloid]] by the [[liver]] and increased uptake by the [[spleen]] and [[bone marrow]] provides evidence of [[portal hypertension]]<ref>{{cite journal |author=Kim YS, Cho SW, Lee KJ, ''et al.'' |title=Tc-99m MIBI SPECT is useful for noninvasively predicting the presence of MDR1 gene-encoded P-glycoprotein in patients with hepatocellular carcinoma |journal=Clin Nucl Med |volume=24 |issue=11 |pages=874–9 |pmid=10551471 |doi= |url=}}</ref>
===Angiography===
===Angiography===
Angiography is currently used for assisting in the placement of catheters for [[CTA]].  The angiographic findings of hepatic perfusion remains essential in transplant assessment, given the variability of the liver's drainage from its arterial and venous supplies.
* The [[Angiogram|angiographic]] findings of [[Liver|hepatic]] [[perfusion]] are essential in [[Organ transplant|transplant]] assessment, given the variability of [[Liver|hepatic]] drainage from its [[Artery|arterial]] and [[Vein|venous]] supplies.
 
===Endoscopy===
* All patients with cirrhosis should undergo a diagnostic endoscopy to document the presence or absence of [[varices]] and to determine the risk for [[Esophageal varices|variceal]] [[Bleeding|hemorrhage]].<ref name="pmid17879356">{{cite journal |author=Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W |title=Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis |journal=[[Hepatology (Baltimore, Md.)]] |volume=46 |issue=3 |pages=922–38 |year=2007  |pmid=17879356 |doi=10.1002/hep.21907 |url=http://dx.doi.org/10.1002/hep.21907 |accessdate=2012-09-06}}</ref><ref name="pmid24328372">{{cite journal |vauthors=Zardi EM, Di Matteo FM, Pacella CM, Sanyal AJ |title=Invasive and non-invasive techniques for detecting portal hypertension and predicting variceal bleeding in cirrhosis: a review |journal=Ann. Med. |volume=46 |issue=1 |pages=8–17 |year=2014 |pmid=24328372 |pmc=4904298 |doi=10.3109/07853890.2013.857831 |url=}}</ref>
* [[Esophageal varices]] are dilated collaterals in the lower [[esophagus]] that interconnect [[Portal venous system|portal]] and [[systemic circulation]] in [[Patient|patients]] with [[portal hypertension]].
* [[Esophageal varices]] appear as irregular, serpiginous, bluish structures running longitudinally in the [[submucosa]] of the [[esophageal]] wall on [[endoscopy]].
* It may be difficult to differentiate small [[varices]] from [[esophageal]] folds and [[Endoscopic ultrasound|EUS]] may be helpful.
* Findings on an [[upper endoscopy]] diagnostic of [[esophageal varices]] include:<ref name="pmid27324725">{{cite journal| author=Abby Philips C, Sahney A| title=Oesophageal and gastric varices: historical aspects, classification and grading: everything in one place. | journal=Gastroenterol Rep (Oxf) | year= 2016 | volume= 4 | issue= 3 | pages= 186-95 | pmid=27324725 | doi=10.1093/gastro/gow018 | pmc=4976684 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27324725  }}</ref>
** Visible [[submucosal]] tortuous veins 
** Congested [[veins]] without compression during air [[insufflation]]
** Grape-like [[Varicose veins|varicose]] veins that may occlude the [[lumen]]<ref name="pmid8076547">{{cite journal |vauthors=Thakeb F, Salem SA, Abdallah M, el Batanouny M |title=Endoscopic diagnosis of gastric varices |journal=Endoscopy |volume=26 |issue=3 |pages=287–91 |year=1994 |pmid=8076547 |doi=10.1055/s-2007-1008969 |url=}}</ref>
[[image:OEV wale.jpg|thumb|300px|left|Esophageal varices-By Samir, via Wikimedia Commons<ref><"https://commons.wikimedia.org/wiki/File%3AEsophageal_varices_-_wale.jpg">via Wikimedia Commons</ref>]]
[[image:Gastric Varices.jpg|thumb|350px|center|Gastric varices-By Jeremias (Own work), via Wikimedia Commons<ref><"https://commons.wikimedia.org/wiki/File%3AGastric_Varices.jpg">via Wikimedia Commons</ref>]]
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* The presence of [[varices]] in patients with cirrhosis is considered an independent risk factor for survival.<ref name="pmid6969201">{{cite journal |author=Lebrec D, De Fleury P, Rueff B, Nahum H, Benhamou JP |title=Portal hypertension, size of esophageal varices, and risk of gastrointestinal bleeding in alcoholic cirrhosis |journal=[[Gastroenterology]] |volume=79 |issue=6 |pages=1139–44 |year=1980 |pmid=6969201 |doi= |url= |accessdate=2012-09-07}}</ref>
* The appearance of [[esophageal varices]] is not diagnostic of [[portal hypertension]] and does not allow for differentiation between [[portal hypertension]] secondary to cirrhosis, pre-[[Liver sinusoid|sinusoidal]] hypertension, or [[Portal vein|portal]] or [[splenic vein]] [[thrombosis]].
* Majority of patients with cirrhosis develop [[varices]] and approximately one third [[Bleeding|bleed]] at some point.<ref name="pmid7026343">{{cite journal |author=Christensen E, Fauerholdt L, Schlichting P, Juhl E, Poulsen H, Tygstrup N |title=Aspects of the natural history of gastrointestinal bleeding in cirrhosis and the effect of prednisone |journal=[[Gastroenterology]] |volume=81 |issue=5 |pages=944–52 |year=1981 |pmid=7026343 |doi= |url= |accessdate=2012-09-07}}</ref>
* The most popular model used to target [[Patient|patients]] with high risk of [[Esophageal varices|variceal]] [[Bleeding|bleed]] is devised by the North Italian Endoscopic Club for the Study and Treatment of [[esophageal varices]].<ref name="pmid3262200">{{cite journal |author= |title=Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicenter study |journal=[[The New England Journal of Medicine]] |volume=319 |issue=15 |pages=983–9 |year=1988 |pmid=3262200 |doi=10.1056/NEJM198810133191505 |url=http://www.nejm.org/doi/abs/10.1056/NEJM198810133191505?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed |accessdate=2012-09-07}}</ref>
* The severity of the underlying [[liver]] disease, presence or absence of red markings on the [[varices]], and [[Esophageal varices|variceal]] size are the most important risk factors for [[bleeding]].
* [[Gastroscopy]] ([[Endoscopy|endoscopic]] examination of the [[esophagus]], stomach and [[duodenum]]) is performed in patients with cirrhosis to exclude the possibility of [[esophageal varices]].
* In patients with [[varices]], [[Prophylaxis|prophylactic]] therapy may include:
** Local therapy:
*** [[Sclerotherapy]]
*** [[Esophageal varices|Variceal]] [[Banding (medical)|banding]]
** Medical therapy:
*** [[Beta blockers]]
 
====Endoscopic Ultrasound (EUS)====
* [[Varices]] may be seen within the [[submucosa]] of the [[esophagus]] and in the periesophageal or perigastric soft tissue.<ref name="pmid2184080">{{cite journal |author=Yasuda K, Cho E, Nakajima M, Kawai K |title=Diagnosis of submucosal lesions of the upper gastrointestinal tract by endoscopic ultrasonography |journal=[[Gastrointestinal Endoscopy]] |volume=36 |issue=2 Suppl |pages=S17–20 |year=1990 |pmid=2184080 |doi= |url= |accessdate=2012-09-07}}</ref>
* In the esophagus, [[Endoscopic ultrasound|EUS]] does not appear to be superior to [[endoscopy]] in the detection of [[esophageal varices]].
* [[Endoscopic ultrasound|EUS]] is invaluable in differentiating [[gastric varices]] from [[Submucosa|submucosal]] [[Tumor|tumors]] and prominent [[Stomach|gastric]] folds.
* The role of [[Endoscopic ultrasound|EUS]] in determining whether or not [[varices]] are obliterated is under evaluation.
* [[Endoscopic ultrasound|EUS]] is a very safe procedure with a complication rate of approximately 0.05%.
* The major complication of [[Endoscopic ultrasound|EUS]] is [[perforation]], which is related to the relatively large diameter and stiffness of the [[Endoscopy|endoscope]] used.
 
====ERCP====
* If a [[Bile duct|biliary]] pathology ([[primary sclerosing cholangitis]] - [[PSC]]) is suspected, [[Endoscopic retrograde cholangiopancreatography|ERCP]] may be performed.
* [[Magnetic resonance cholangiopancreatography|MRCP]] (MRI of [[Bile duct|biliary tract]] and [[pancreas]]) is usually sufficient for diagnosis, but [[Endoscopic retrograde cholangiopancreatography|ERCP]] allows for particular interventions, such as placement of a biliary [[stent]] or extraction of [[gallstones]].
 
=== Three dimensional portal venography ===
* Three dimensional [[portal]] [[venography]] may be helpful in the diagnosis of [[Esophageal varices|gasteroesophageal varices]].
* Findings on a [[portal]] [[venography]] diagnostic of [[esophageal varices]] include:<ref name="pmid18373819">{{cite journal| author=Agarwal A, Jain M| title=Multidetector CT portal venography in evaluation of portosystemic collateral vessels. | journal=J Med Imaging Radiat Oncol | year= 2008 | volume= 52 | issue= 1 | pages= 4-9 | pmid=18373819 | doi=10.1111/j.1440-1673.2007.01903.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18373819  }}</ref><ref name="pmid12235335">{{cite journal| author=Kang HK, Jeong YY, Choi JH, Choi S, Chung TW, Seo JJ et al.| title=Three-dimensional multi-detector row CT portal venography in the evaluation of portosystemic collateral vessels in liver cirrhosis. | journal=Radiographics | year= 2002 | volume= 22 | issue= 5 | pages= 1053-61 | pmid=12235335 | doi=10.1148/radiographics.22.5.g02se011053 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12235335  }}</ref>
** Reverse flow in [[Portocaval anastomoses|porto-systemic shunts]]
** [[Collateral]] [[Vein|veins]] draining into [[Inferior vena cava|inferior vena cava (IVC)]]
** Other [[collateral]] [[veins]]
 
[[image:Venography.png|thumb|600px|left|Venography Source:Open-i<ref>{{cite web |url=https://openi.nlm.nih.gov/detailedresult.php?img=PMC3859884_kjped-56-500-g001&req=4 |title=(A) Angiographic portography revealed portal vein, coro &#124; Open-i |format= |work= |accessdate=}}</ref>]]
[[image:Portal-vein-anatomy.jpg|thumb|500px|center|Venography-Case courtesy of Dr Omar Bashir, via radiopaedia.org<ref name="https://radiopaedia.org/">Radiopaedia.org. From the case <"https://radiopaedia.org/cases/16761">rID: 16761</ref>]]
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==References==
==References==
{{reflist|2}}
{{reflist|2}}


 
[[Category:Gastroenterology]]
[[Category:Hepatology]]
[[Category:Disease]]


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Latest revision as of 15:05, 14 December 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2] Sudarshana Datta, MD [3]

Overview

Tc-99m labeled sulfur may be used in nuclear imaging to provide some indication of hepatic function in cirrhotic patients. In candidates for liver transplant, CTA is used to asses the drainage of the liver. All patients with cirrhosis must undergo a diagnostic endoscopy for the evaluation of varices. Gastric endoscopy is an option if gastric varices are suspected, and endoscopic ultrasound may also help in the visualization of varices. ERCP is performed if a biliary pathology such as primary sclerosing cholangitis is suspected as the underlying cause of cirrhosis.

Other Imaging Findings

Nuclear Imaging

Angiography

Endoscopy

Esophageal varices-By Samir, via Wikimedia Commons[8]
Gastric varices-By Jeremias (Own work), via Wikimedia Commons[9]


Endoscopic Ultrasound (EUS)

ERCP

Three dimensional portal venography

Venography Source:Open-i[16]
Venography-Case courtesy of Dr Omar Bashir, via radiopaedia.org[17]



References

  1. Nishikawa H, Osaki Y (2015). "Liver Cirrhosis: Evaluation, Nutritional Status, and Prognosis". Mediators Inflamm. 2015: 872152. doi:10.1155/2015/872152. PMC 4606163. PMID 26494949.
  2. McLaren MI, Fleming JS, Walmsley BH, Ackery DM, Taylor I, Karran SJ (1985). "Dynamic liver scanning in cirrhosis". Br J Surg. 72 (5): 394–6. PMID 3995244.
  3. Kim YS, Cho SW, Lee KJ; et al. "Tc-99m MIBI SPECT is useful for noninvasively predicting the presence of MDR1 gene-encoded P-glycoprotein in patients with hepatocellular carcinoma". Clin Nucl Med. 24 (11): 874–9. PMID 10551471.
  4. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W (2007). "Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis". Hepatology (Baltimore, Md.). 46 (3): 922–38. doi:10.1002/hep.21907. PMID 17879356. Retrieved 2012-09-06.
  5. Zardi EM, Di Matteo FM, Pacella CM, Sanyal AJ (2014). "Invasive and non-invasive techniques for detecting portal hypertension and predicting variceal bleeding in cirrhosis: a review". Ann. Med. 46 (1): 8–17. doi:10.3109/07853890.2013.857831. PMC 4904298. PMID 24328372.
  6. Abby Philips C, Sahney A (2016). "Oesophageal and gastric varices: historical aspects, classification and grading: everything in one place". Gastroenterol Rep (Oxf). 4 (3): 186–95. doi:10.1093/gastro/gow018. PMC 4976684. PMID 27324725.
  7. Thakeb F, Salem SA, Abdallah M, el Batanouny M (1994). "Endoscopic diagnosis of gastric varices". Endoscopy. 26 (3): 287–91. doi:10.1055/s-2007-1008969. PMID 8076547.
  8. <"https://commons.wikimedia.org/wiki/File%3AEsophageal_varices_-_wale.jpg">via Wikimedia Commons
  9. <"https://commons.wikimedia.org/wiki/File%3AGastric_Varices.jpg">via Wikimedia Commons
  10. Lebrec D, De Fleury P, Rueff B, Nahum H, Benhamou JP (1980). "Portal hypertension, size of esophageal varices, and risk of gastrointestinal bleeding in alcoholic cirrhosis". Gastroenterology. 79 (6): 1139–44. PMID 6969201. |access-date= requires |url= (help)
  11. Christensen E, Fauerholdt L, Schlichting P, Juhl E, Poulsen H, Tygstrup N (1981). "Aspects of the natural history of gastrointestinal bleeding in cirrhosis and the effect of prednisone". Gastroenterology. 81 (5): 944–52. PMID 7026343. |access-date= requires |url= (help)
  12. "Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicenter study". The New England Journal of Medicine. 319 (15): 983–9. 1988. doi:10.1056/NEJM198810133191505. PMID 3262200. Retrieved 2012-09-07.
  13. Yasuda K, Cho E, Nakajima M, Kawai K (1990). "Diagnosis of submucosal lesions of the upper gastrointestinal tract by endoscopic ultrasonography". Gastrointestinal Endoscopy. 36 (2 Suppl): S17–20. PMID 2184080. |access-date= requires |url= (help)
  14. Agarwal A, Jain M (2008). "Multidetector CT portal venography in evaluation of portosystemic collateral vessels". J Med Imaging Radiat Oncol. 52 (1): 4–9. doi:10.1111/j.1440-1673.2007.01903.x. PMID 18373819.
  15. Kang HK, Jeong YY, Choi JH, Choi S, Chung TW, Seo JJ; et al. (2002). "Three-dimensional multi-detector row CT portal venography in the evaluation of portosystemic collateral vessels in liver cirrhosis". Radiographics. 22 (5): 1053–61. doi:10.1148/radiographics.22.5.g02se011053. PMID 12235335.
  16. "(A) Angiographic portography revealed portal vein, coro | Open-i".
  17. Radiopaedia.org. From the case <"https://radiopaedia.org/cases/16761">rID: 16761

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