Ultrasonography of cirrhosis

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Author: Mikael Häggström [notes 1]

Contents

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" 1]

In patients with known cirrhosis, surveillance ultrasonography of hepatocellular cancer (HCC) is indicated, generally every 6 months.[4]

Diagnosis

 
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]
  • Relative expansion of the caudate lobe, creating a ratio of caudate width compared to right lobe width of >0.65 (sensitivity 43-84%, specificity 100%)[5]
  • Reduction of the transverse diameter (<30 mm) of the medial segment of the left lobe (segment IV).[5]
  • Fatty change which is variable [5]
  • Signs of portal hypertension[5]
  • Dilated portal vein: >13 mm (sensitivity 42%, specificity 95-100%)[5]
  • Slow portal venous flow on Doppler: <15 cm/sec[5]
  • Reversal or alternating directions of portal venous flow[5]
  • Portal venous thrombosis with or without cavernous transformation[5]
  • Dilated superior mesenteric vein and splenic vein of > 10mm.[5] These should be measured during deep inspiration since it may vary with respiration.[5]
  • Loss of respiratory variation in superior mesenteric vein and splenic vein on spectral Doppler[5]
  • Re-canalisation and hepatofugal paraumbilical venous flow.[5]
  • Dilated porto-systemic collaterals.[5]
  • Portalisation of hepatic vein flow on Doppler[5]
  • Corkscrew appearance of hepatic arteries[5]
  • Increased velocity in hepatic artery[5]
  • Splenomegaly[5]
  • Ascites[5]
 
Doppler ultrasonography of the portal vein over 5 seconds, showing peaks of maximal velocity, as well as points of minimal velocity.
  • Portal flow pulsatility: An increased portal vein pulsatility is an indicator of cirrhosis, 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:
Pulsatility indices (PI)
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

  1. ↑ 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.

References

  1. ↑ 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:10.1001/jama.2012.186. PMID 22357834. 
  2. ↑ 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:10.1093/gastro/gox012. ISSN 2052-0034. 
  3. ↑ 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:10.3748/wjg.v23.i10.1735. ISSN 1007-9327. 
  4. ↑ 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:10.2147/JHC.S105777. ISSN 2253-5969. 
  5. ↑ 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 5.15 5.16 5.17 5.18 5.19 5.20 Dr Yuranga Weerakkody, A.Prof Frank Gaillard et al.. Cirrhosis. Radiopaedia. Retrieved on 2018-06-16.
  6. ↑ 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:10.14366/usg.15020. ISSN 2288-5919. 
  7. ↑ 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:10.1093/eurheartj/eht307.P627. ISSN 0195-668X. 
  8. ↑ 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. 


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