2. LIVER CIRRHOSIS
Introduction.
• Cirrhosis is a chronic liver condition in which the liver parenchyma and
architecture are destroyed, fibrous tissue is laid down, and regenerative nodules
are formed.
• In its early stages, it is usually asymptomatic, as it may take months or even years
before damage becomes apparent.
• Cirrhosis affects the entire liver and is considered an end-stage condition
resulting from liver damage caused by chronic alcohol abuse and drugs.
3. Cont....
• Cirrhosis may be classified as micronodular (nodules 0.1 to 1 cm in diameter) or
macronodular (nodules up to 5 cm in diameter).
• The process of cirrhosis is chronic and progressive, with liver cell failure and
portal hypertension as the end stage.
• Micronodular cirrhosis is most commonly the result of chronic alcohol abuse,
whereas macronodular cirrhosis is caused by chronic viral hepatitis or other
infection.
4. EPIDERMIOLOGY
• The demographics of cirrhosis reflect the underlying causes. Alcoholism and viral
hepatitis from intravenous drug use are the common causes.
• The distribution of underlying etiology will vary regionally, with viral hepatitis
being much higher in the developing world, especially Asia.
5. Epidemiology cont.….
• A typical distribution of causality in Western nations is a follows:
• Alcohol: 60-70%
• Viral hepatitis: 10%
• -hepatitis B virus most common in sub-Saharan Africa and Asia
• -hepatitis C virus most common in the Western countries and Japan
• Non-alcoholic fatty liver disease(non-alcoholic steatohepatitis): 10-15%
6. Epidemiology cont.….
• Biliary disease: e.g. primary sclerosing cholangitis (PSC), primary biliary
cholangitis (PBC): 5-10%
• Metabolic disease: e.g. hereditary hemochromatosis, Wilson disease, alpha-1-
antitrypsin deficiency: 5% autoimmune hepatitis
• Vascular disease: e.g. congestive hepatopathy (right heart failure), Budd-Chiari
syndrome, hepatic veno-occlusive disease (rare)
• Cystic fibrosis: uncommon but increasing with increased survival
• Medications: e.g. methotrexate
7. PATHOLOGY
• Focal hepatocellular necrosis caused by a variety of insults is accompanied by the
three characteristics of cirrhosis 3:
fibrosis
• Is an excessive accumulation of fibrous connective tissue (components of the
extracellular matrix (ECM) such as collagen and fibronectin) in and around
inflamed or damaged tissue, which can lead to permanent scarring, organ
malfunction and, ultimately, death, as seen in end-stage liver disease
8. Pathology cont.….
nodular regeneration
• a rare liver condition characterized by a widespread benign transformation of the
hepatic parenchyma into small regenerative nodules
distortion of hepatic architecture
• atrophy of the medial segment and right lobe and hypertrophy of the lateral
segment and caudate lobe.
• Although traditionally cirrhosis has been divided into micro-and macronodular
cirrhosis, many entities begin as micronodular (<3 mm) and progress to
macronodular (e.g. alcoholic cirrhosis) and thus it is of limited utility as a
classification scheme.
9. CLINICAL PRESENTATION
Clinical presentation.
• Patients with acute cirrhosis may seem symptomatic
• The patient may also have symptoms that include; nausea, flatulence, ascites,
light-colored stools, weakness, abdominal pain, varicosities.
The classic clinical presentation of a patient with cirrhosis is
• hepatomegaly(early stage)
• Jaundice and
• Ascites.
10. Clinical presentation cont.….
• Chronic cirrhosis patient symptoms include; nausea, anorexia, weight loss,
jaundice, dark urine, fatigue and varicosities.
• Chronic cirrhosis may progress to liver failure and portal hypertension.
11. RADIOLOGICAL FEATURES
• Hepatomegaly (early stage)
• Hepatic Atrophy (late stage)
• Hypertrophy of caudate lobe with shrinkage of the right lobe.
• Irregularity (modularity)of the liver surface.
• Regenerating modularity.
• Coarsening of hepatic parenchymal echotexture.
• Splenomegaly.
• Portal hypertension.
12. Imaging modalities for evaluation of Liver cirrhosis.
• Computed tomography (CT), Magnetic resonance imaging (MRI) and Ultrasound are
best imaging modalities for evaluation of liver cirrhosis.
• Conventional radiographic signs of cirrhosis are few and not specific. Morphologic
changes in the liver from cirrhosis may cause displacement of other abdominal organs
such as the stomach, duodenum, colon, gallbladder, and kidney.
13. 01. Ultrasound features
• Ultrasound is a major screening tool for cirrhosis and its complications. It is also useful
to aid for biopsy.
• Appearances include; surface nodularity: 88% sensitive, overall coarse and
heterogeneous echotexture, segmental hypertrophy/atrophy, caudate width: right lobe
width (84% sensitive), signs of portal hypertension, Doppler flow changes, enlarged
portal vein: >13 mm (42% sensitive).
• Other features are like low portal venous flow <15 cm/sec, reversal or to-and-fro portal
venous flow, portal venous thrombosis +/- cavernous transformation, enlarged superior
mesenteric vein and splenic vein: >10 mm, splenomegaly, ascites, fatty change
(variable)
14. Ultrasound features
• The liver is shrunken.
• Dilated portal vein lumen
• Irregular liver margins
• Ascites around the liver
15. Computed tomography features
• Computed tomographic scan (CT scan), is the primary modality for evaluating the
complications arising from cirrhosis but insensitive in early cirrhosis.
• Fatty infiltration of the liver is well visualized by CT
• CT is also of value in assessing the presence of complications of cirrhosis such as
ascites and hepatocellular carcinoma(HCC).
16. Computed tomography image
• Multicentric HCC with a variegated appearance. (a) Arterial phase contrast-
enhanced axial CT image shows a large heterogeneous mass that enhances
intensely with multiple adjacent nodular areas with different attenuation
patterns (long arrow).
17. CT image cont..
• Macronodular regenerative nodules, due to alcohol-induced cirrhosis. (a) Arterial phase
CT shows multiple nodular isodense lesions deforming the liver margin (arrows). The
contour bulge caused by the nodular regeneration may help to detect the lesions.
18. Magnetic resonance features
• MRI is also insensitive in early cirrhosis but has a significant role in screening
cirrhotic livers for small hepatocellular carcinomas. MRI findings include:
• morphologic changes (same as on CT and ultrasound)
• regenerative nodules (or cirrhotic nodules)
• Lesions in the liver that have been identified on sonography, MRI, or CT are highly
recommended to be further evaluated with MRI of the abdomen, with and without
contrast, to conclusively differentiate between benign and malignant lesions. If the
patient is unable to tolerate MRI contrast, CT of the abdomen is the next modality
recommended to delineate the liver lesion in question.
19. MRI image
• Fibrosis and regenerative nodules. Transverse STIR image shows a reticular pattern
of the fibrotic bands surrounding hypointense regenerative nodules
20. Complications
• The scarring and formation of regenerative nodules associated with cirrhosis
result in serious complications.
• The functional impairments caused by cirrhosis are impaired liver function
caused by hepatocyte damage, generally resulting in jaundice, and portal
hypertension. Because of interference of portal blood flow through the liver,
portal hypertension may lead to development of collateral venous connections
to the venae cava . Most commonly, such connections involve the esophageal
veins, which dilate to become esophageal varices.
• Also, patients with cirrhosis have a tendency of bleeding because the liver is
unable to make the necessary clotting factors found in plasma or as a result of an
esophageal variceal rupture. Such hemorrhaging may be, in fact, the first
indication of portal hypertension.
21. Complications cont.…..
• Ascites, the accumulation of fluid within the peritoneal cavity is also seen as a
result of portal hypertension and the leakage of excessive fluids from the portal
capillaries .It is associated with approximately 50% of deaths from cirrhosis.
• Ascites may also result from chronic hepatitis, congestive heart failure, renal
failure, and certain cancers.
• Abdominal sonography is commonly used in the detection or confirmation of
ascites.
• In summary the complications of liver cirrhosis are; Liver failure, ascites, portal
hypertension, Hepatocellular carcinoma (HCC)
22. Differential diagnosis
There are several conditions that can potentially mimic cirrhosis on imaging including:
Pseudocirrhosis.
• Describes morphological changes of the liver that closely mimic cirrhosis, without
the typical histopathological changes seen in cirrhosis. Most commonly occurs in
patients with metastatic breast cancer
Widespread (miliary type) liver metastases
Budd-Chiari syndrome (particularly chronic)
• A rare heterogeneous liver disease that is characterized by obstruction of the hepatic
venous outflow tract
23. Differential diagnosis cont.…
Fulminant hepatic failure
• Life threatening condition that happens when liver function rapidly deteriorates ue to
liver cells damage.
Idiopathic portal hypertension
• non cirrhotic portal hypertension
Nodular regenerative hyperplasia of the liver
• A rare liver condition characterized by a widespread benign transformation of the
hepatic parenchyma into small regenerative nodules. It may lead to the development
of non-cirrhotic portal hypertension.
