Difference between revisions of "Ultrasonography of cirrhosis"
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|author1=[[User:Mikael Häggström|Mikael Häggström]] | |author1=[[User:Mikael Häggström|Mikael Häggström]] | ||
|author2= | |author2= | ||
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| + | ==Planning== | ||
| + | ;Need of investigation | ||
| + | The diagnosis of cirrhosis can be made by physical examination and blood testing alone,<ref>{{cite journal|last=Udell|first=JA |author2=Wang, CS |author3=Tinmouth, J |author4=FitzGerald, JM |author5=Ayas, NT |author6=Simel, DL |author7=Schulzer, M |author8=Mak, E |author9=Yoshida, EM|title=Does this patient with liver disease have cirrhosis?|journal=JAMA: The Journal of the American Medical Association|date=Feb 22, 2012|volume=307|issue=8|pages=832–42|pmid=22357834|doi=10.1001/jama.2012.186}}</ref> but ultrasonography is very helpful as an additional diagnostic tool at least in subtle disease. | ||
| + | |||
| + | ;Choice of modality | ||
| + | Ultrasonography is the first-line modality of medical imaging in patients with suspected cirrhosis and/or portal hypertension.<ref name="ProcopetBerzigotti2017">{{cite journal|last1=Procopet|first1=Bogdan|last2=Berzigotti|first2=Annalisa|title=Diagnosis of cirrhosis and portal hypertension: imaging, non-invasive markers of fibrosis and liver biopsy|journal=Gastroenterology Report|volume=5|issue=2|year=2017|pages=79–89|issn=2052-0034|doi=10.1093/gastro/gox012}}</ref> US is also typically the initial, first-line modality choice for the diagnosis and follow-up of portal hypertension.<ref name="BandaliMirakhur2017">{{cite journal|last1=Bandali|first1=Murad Feroz|last2=Mirakhur|first2=Anirudh|last3=Lee|first3=Edward Wolfgang|last4=Ferris|first4=Mollie Clarke|last5=Sadler|first5=David James|last6=Gray|first6=Robin Ritchie|last7=Wong|first7=Jason Kam|title=Portal hypertension: Imaging of portosystemic collateral pathways and associated image-guided therapy|journal=World Journal of Gastroenterology|volume=23|issue=10|year=2017|pages=1735|issn=1007-9327|doi=10.3748/wjg.v23.i10.1735}}</ref> For cirrhosis, it should be done without IV contrast. | ||
| + | |||
| + | ===How soon=== | ||
| + | In Swedish practice, ultrasonography for suspected cirrhosis should be done within 2 months.<ref group="notes">{{NU Hospital Group}}</ref> | ||
| − | + | In patients with known cirrhosis, surveillance [[ultrasonography of hepatocellular cancer]] (HCC) is indicated, generally every 6 months.<ref name="FateenRyder2017">{{cite journal|last1=Fateen|first1=Waleed|last2=Ryder|first2=Stephen|title=Screening for hepatocellular carcinoma: patient selection and perspectives|journal=Journal of Hepatocellular Carcinoma|volume=Volume 4|year=2017|pages=71–79|issn=2253-5969|doi=10.2147/JHC.S105777}}</ref> | |
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==Diagnosis== | ==Diagnosis== | ||
| + | [[File:Ascites ultrasound 2.JPG|thumb|Irregular liver surface and ascites.]] | ||
Cirrhosis is indicated by: | Cirrhosis is indicated by: | ||
*Surface nodularity: (sensitivity 88%, specificity 82-95%)<ref name=Radiopaedia-Cirrhosis>{{cite web|url=https://radiopaedia.org/articles/cirrhosis|title=Cirrhosis|website=Radiopaedia|accessdate=2018-06-16|author=Dr Yuranga Weerakkody, A.Prof Frank Gaillard et al.}}</ref> | *Surface nodularity: (sensitivity 88%, specificity 82-95%)<ref name=Radiopaedia-Cirrhosis>{{cite web|url=https://radiopaedia.org/articles/cirrhosis|title=Cirrhosis|website=Radiopaedia|accessdate=2018-06-16|author=Dr Yuranga Weerakkody, A.Prof Frank Gaillard et al.}}</ref> | ||
| Line 17: | Line 25: | ||
*Fatty change which is variable <ref name=Radiopaedia-Cirrhosis/> | *Fatty change which is variable <ref name=Radiopaedia-Cirrhosis/> | ||
*Signs of portal hypertension<ref name=Radiopaedia-Cirrhosis/> | *Signs of portal hypertension<ref name=Radiopaedia-Cirrhosis/> | ||
| − | :*Dilated portal vein: >13 mm (sensitivity 42%, specificity 95-100%)<ref name=Radiopaedia-Cirrhosis/> | + | :*Portal vein measurement and Doppler: |
| − | :*Slow portal venous flow on Doppler: <15 cm/sec<ref name=Radiopaedia-Cirrhosis/> | + | ::*Dilated portal vein: >13 mm (sensitivity 42%, specificity 95-100%)<ref name=Radiopaedia-Cirrhosis/> |
| − | :*Reversal or alternating directions of portal venous flow<ref name=Radiopaedia-Cirrhosis/> | + | ::*Slow portal venous flow on Doppler: <15 cm/sec<ref name=Radiopaedia-Cirrhosis/> |
| − | :*Portal venous thrombosis | + | ::*Reversal or alternating directions of portal venous flow<ref name=Radiopaedia-Cirrhosis/> |
| − | :* | + | ::*Portal venous thrombosis |
| − | :* | + | ::*Cavernous transformation of the portal vein,<ref name=Radiopaedia-Cirrhosis/> appearing like multiple veins. |
| − | :* | + | :*Hepatic artery Doppler: |
| − | :* | + | ::*Increased velocity in hepatic artery<ref name=Radiopaedia-Cirrhosis/> |
| − | + | ::*Corkscrew appearance of hepatic arteries<ref name=Radiopaedia-Cirrhosis/> | |
| − | + | :*Splenomegaly<ref name=Radiopaedia-Cirrhosis/> (see [[ultrasonography of the spleen]] for size cutoffs) | |
| − | + | :*Ascites,<ref name=Radiopaedia-Cirrhosis/> with fluid seen in the hepatorenal recess. | |
| − | + | [[File:Doppler ultrasonography of the portal vein in cirrhosis.jpg|thumb|Doppler ultrasonography of the portal vein over 5 seconds, showing peaks of '''max'''imal velocity, as well as points of '''min'''imal velocity.]] | |
| − | : | + | :''For further signs of portal hypertension, which may be used upon specific portal hypertension referral, see '''[[Ultrasonography of portal hypertension]]''' |
| + | *Portal flow pulsatility: An increased portal vein pulsatility is an indicator of cirrhosis (even without portal hypertension), but may also be caused by an increased right atrial pressure.<ref name="IranpourLall2016">{{cite journal|last1=Iranpour|first1=Pooya|last2=Lall|first2=Chandana|last3=Houshyar|first3=Roozbeh|last4=Helmy|first4=Mohammad|last5=Yang|first5=Albert|last6=Choi|first6=Joon-Il|last7=Ward|first7=Garrett|last8=Goodwin|first8=Scott C|title=Altered Doppler flow patterns in cirrhosis patients: an overview|journal=Ultrasonography|volume=35|issue=1|year=2016|pages=3–12|issn=2288-5919|doi=10.14366/usg.15020}}</ref> Portal vein pulsatility can be quantified by pulsatility indices (PI), where an index above a certain cutoff indicates pathology: | ||
| + | |||
| + | {|class="wikitable" | ||
| + | |+Pulsatility indices (PI) | ||
| + | ! Index !! Calculation !! Cutoff | ||
| + | |- | ||
| + | | Average-based || (Max - Min) / Average<ref name="IranpourLall2016"/> || 0.5<ref name="IranpourLall2016"/> | ||
| + | |- | ||
| + | | Max-relative || (Max - Min) / Max<ref name="GoncalvesovaVarga2013">{{cite journal|last1=Goncalvesova|first1=E.|last2=Varga|first2=I.|last3=Tavacova|first3=M.|last4=Lesny|first4=P.|title=Changes of portal vein flow in heart failure patients with liver congestion|journal=European Heart Journal|volume=34|issue=suppl 1|year=2013|pages=P627–P627|issn=0195-668X|doi=10.1093/eurheartj/eht307.P627}}</ref> || 0.5<ref name="GoncalvesovaVarga2013"/><ref name=Dancygier2009>[https://books.google.se/books?id=ZfJN6NS0ZY4C&pg=PA367 Page 367] in: {{cite book|title=Clinical Hepatology: Principles and Practice of Hepatobiliary Diseases|volume=1|author=Henryk Dancygier|publisher=Springer Science & Business Media|year=2009|isbn=9783540938422}}</ref> - 0.54<ref name=Dancygier2009/> | ||
| + | |} | ||
==Surveillance== | ==Surveillance== | ||
| − | In patients with a diagnosis, surveillance [[ultrasonography of hepatocellular cancer]] (HCC) is indicated, generally every 6 months.<ref name="FateenRyder2017">{{cite journal|last1=Fateen|first1=Waleed|last2=Ryder|first2=Stephen|title=Screening for hepatocellular carcinoma: patient selection and perspectives|journal=Journal of Hepatocellular Carcinoma|volume=Volume 4|year=2017|pages=71–79|issn=2253-5969|doi=10.2147/JHC.S105777}}</ref> | + | In patients with a diagnosis of cirrhosis, surveillance [[ultrasonography of hepatocellular cancer]] (HCC) is indicated, generally every 6 months.<ref name="FateenRyder2017">{{cite journal|last1=Fateen|first1=Waleed|last2=Ryder|first2=Stephen|title=Screening for hepatocellular carcinoma: patient selection and perspectives|journal=Journal of Hepatocellular Carcinoma|volume=Volume 4|year=2017|pages=71–79|issn=2253-5969|doi=10.2147/JHC.S105777}}</ref> |
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| − | + | {{Bottom}} | |
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Latest revision as of 16:36, 20 March 2019
Author:
Mikael Häggström [notes 1]
Planning
- Need of investigation
The diagnosis of cirrhosis can be made by physical examination and blood testing alone,[1] but ultrasonography is very helpful as an additional diagnostic tool at least in subtle disease.
- Choice of modality
Ultrasonography is the first-line modality of medical imaging in patients with suspected cirrhosis and/or portal hypertension.[2] US is also typically the initial, first-line modality choice for the diagnosis and follow-up of portal hypertension.[3] For cirrhosis, it should be done without IV contrast.
How soon
In Swedish practice, ultrasonography for suspected cirrhosis should be done within 2 months.[notes 2]
In patients with known cirrhosis, surveillance ultrasonography of hepatocellular cancer (HCC) is indicated, generally every 6 months.[4]
Diagnosis
File:Ascites ultrasound 2.JPG
Irregular liver surface and ascites.
Cirrhosis is indicated by:
- Surface nodularity: (sensitivity 88%, specificity 82-95%)[5]
- General coarse and heterogeneous texture[5]
- Segmental hypertrophy or atrophy[5]
- Portal vein measurement and Doppler:
- Hepatic artery Doppler:
- Splenomegaly[5] (see ultrasonography of the spleen for size cutoffs)
- Ascites,[5] with fluid seen in the hepatorenal recess.
File:Doppler ultrasonography of the portal vein in cirrhosis.jpg
Doppler ultrasonography of the portal vein over 5 seconds, showing peaks of maximal velocity, as well as points of minimal velocity.
- For further signs of portal hypertension, which may be used upon specific portal hypertension referral, see Ultrasonography of portal hypertension
- Portal flow pulsatility: An increased portal vein pulsatility is an indicator of cirrhosis (even without portal hypertension), but may also be caused by an increased right atrial pressure.[6] Portal vein pulsatility can be quantified by pulsatility indices (PI), where an index above a certain cutoff indicates pathology:
| Index | Calculation | Cutoff |
|---|---|---|
| Average-based | (Max - Min) / Average[6] | 0.5[6] |
| Max-relative | (Max - Min) / Max[7] | 0.5[7][8] - 0.54[8] |
Surveillance
In patients with a diagnosis of cirrhosis, surveillance ultrasonography of hepatocellular cancer (HCC) is indicated, generally every 6 months.[4]
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Radlines:Authorship for details.
- ↑ NU Hospital Group, Sweden
References
- ↑ Udell, JA; Wang, CS; Tinmouth, J; FitzGerald, JM; Ayas, NT; Simel, DL; Schulzer, M; Mak, E; et al. (Feb 22, 2012). "Does this patient with liver disease have cirrhosis? ". JAMA: The Journal of the American Medical Association 307 (8): 832–42. doi:. PMID 22357834.
- ↑ Procopet, Bogdan; Berzigotti, Annalisa (2017). "Diagnosis of cirrhosis and portal hypertension: imaging, non-invasive markers of fibrosis and liver biopsy ". Gastroenterology Report 5 (2): 79–89. doi:. ISSN 2052-0034.
- ↑ Bandali, Murad Feroz; Mirakhur, Anirudh; Lee, Edward Wolfgang; Ferris, Mollie Clarke; Sadler, David James; Gray, Robin Ritchie; Wong, Jason Kam (2017). "Portal hypertension: Imaging of portosystemic collateral pathways and associated image-guided therapy ". World Journal of Gastroenterology 23 (10): 1735. doi:. ISSN 1007-9327.
- ↑ 4.0 4.1 Fateen, Waleed; Ryder, Stephen (2017). "Screening for hepatocellular carcinoma: patient selection and perspectives ". Journal of Hepatocellular Carcinoma Volume 4: 71–79. doi:. ISSN 2253-5969.
- ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 5.12 5.13 5.14 Dr Yuranga Weerakkody, A.Prof Frank Gaillard et al.. Cirrhosis. Radiopaedia. Retrieved on 2018-06-16.
- ↑ 6.0 6.1 6.2 Iranpour, Pooya; Lall, Chandana; Houshyar, Roozbeh; Helmy, Mohammad; Yang, Albert; Choi, Joon-Il; Ward, Garrett; Goodwin, Scott C (2016). "Altered Doppler flow patterns in cirrhosis patients: an overview ". Ultrasonography 35 (1): 3–12. doi:. ISSN 2288-5919.
- ↑ 7.0 7.1 Goncalvesova, E.; Varga, I.; Tavacova, M.; Lesny, P. (2013). "Changes of portal vein flow in heart failure patients with liver congestion ". European Heart Journal 34 (suppl 1): P627–P627. doi:. ISSN 0195-668X.
- ↑ 8.0 8.1 Page 367 in: Henryk Dancygier (2009). Clinical Hepatology: Principles and Practice of Hepatobiliary Diseases . 1. Springer Science & Business Media. ISBN 9783540938422.
