Ultrasound of liver for Liver Cirrhosis

Ultrasound of liver for Liver Cirrhosis

 Ultrasound features of liver cirrhosis

Liver cirrhosis is a diffuse process 

characterized by fibrosis and the conversion of normal liver architecture into structurally abnormal nodules three pathologic processes leads to cirrhosis cell death fibrosis and regeneration the sonographic features of cirrhosis vary during the course of the disease early serotic changes include hepatomegaly and possible textural changes these imaging features alone are non-specific and unreliable in detecting early histologic changes of cirrhosis with superimposed fatty infiltration the parenchymal echogenicity increased as compared to the normal renal cortex more specific ultrasound features of cirrhosis are seen with late disease one of these features is volume redistribution in early stages of cirrhosis the liver may be enlarged however in advance stages the liver is often small with relative enlargement of the caudate and left lobes compared to the right lobe the ratio of the caudate lobe width to the right lobe width is an indicator of cirrhosis a ratio of 0.65 is considered indicative of cirrhosis however volume redistribution is seen also in patients with bud kyrie syndrome irregular hepatic surface is a sign of cirrhosis it is easily identified in the presence of perihepatic ascites as seen in this case surface irregularity is due to the presence of regenerating nodules and fibrosis in absence of ascites the liver surface is difficult to assess however this can be facilitated by using high frequency transducer as seen in the images on the right side of the screen coarse hepatic echo texture is seen in liver cirrhosis due to fibrosis and regenerating nodules special attention should be given to highly heterogeneous liver structure particularly if this heterogeneity is limited to certain areas in these conditions the presence of a diffuse hepatocellular carcinoma should be suspected.

Regenerating nodules are regenerating 

hepatocytes

Surrounded by fibrotic septae 

on ultrasound regenerating nodules are isoechoic or hypoechoic with a thin echogenic border that corresponding to fiber fatty connective tissue a frequent sign in liver cirrhosis is the thickening of the gallbladder wall due to edema secondary to hypoalbuminemia portal hypertension and lymphatic stasis in cases of liver cirrhosis the gallbladder wall thickness can reach up to 10 millimeters in advanced liver cirrhosis and as a result of fibrosis the portal circulation resistance is increased this results in portal hypertension one of the first signs of portal hypertension in ultrasound is the increased diameter of the portal vein greater than 13 millimeters with lack of respiratory variation other signs of portal hypertension are dilated portosystemic venous collaterals the dilated collaterals can be seen on sonography at the periplasmic region and around the gallbladder on ultrasound, collaterals appear as multiple anechoic epigenous structures that communicate with each other on color Doppler examination they show venous flow recanalization of the umbilical vein is a sign of severe portal hypertension it can be found in 10 to 20 percent of cases of advanced liver cirrhosis the recanalized umbilical vein can be traced starting from the left branch of the portal vein continuing to the abdominal wall downwards towards the umbilicus splenomegaly is frequently seen in cases of liver cirrhosis.

It is seen in approximately 80 percent 

of the cases

in these patients splenomegaly is

frequently exceeding 15 centimeters in

bipolar diameter

ascites is frequently encountered in

patients with decompensated liver

cirrhosis

Ultrasound is a very sensitive 

method to detect ascites passive hepatic congestion is passive edema of the liver

secondary to vascular stasis as a 

complication related to heart failure in the early stage, the liver is enlarged

causing right upper quadrant discomfort 

ultrasound signs are dilated hepatic veins and dilated inferior vena cava the dilated hepatic veins are well visible up to the periphery of the liver the hepatic vein diameter can be

measured two centimeters from the 

junction with the inferior vena cava a diameter larger than 10 millimeters is

considered 

abnormal on doppler examination there is a loss of normal respiratory

variability of the hepatic veins 

another ultrasound sign of heart failure is the presence of ascites the invariable amount the presence of pleural effusion is also relatively frequent in patients with heart failure bud kyrie syndrome is a rare cause of portal hypertension and liver failure the disease is characterized by impaired hepatic venous drainage the causative lesion can be located at any portion from the hepatic veins to the upper the portion of the inferior vena cava bud kyrie syndrome is commonly classified into primary and secondary primary bud kyrie syndrome is caused by a venous obstruction that is mostly due to hepatic vein thrombosis and less frequently due to hepatic vein stenosis secondary bud kyrie syndrome is caused by hepatic vein obstruction due to external compression by a tumor or by an infectious process hepatic venous obstruction causes elevated sinusoidal pressure and liver congestion when hepatic venous obstruction develops in more than one hepatic vein at different time intervals atrophic liver segments can be found adjacent to hypertrophic segments the presence of atrophic and hypertrophic hepatic segments is called hepatic dysmorphism.

The most characteristic feature of 

hepatic dysmorphism is irregular liver contour ultrasound features of bud kyrie

syndrome 

is classified into direct signs including hepatic veins thrombosis and hepatic vein stenosis and indirect

indications 

including parenchymal changes morphologic changes regenerating nodules portal hypertension

intra and extrahepatic collaterals 

hepatic vein thrombosis can be total or partial focal or extensive and may involve one or more hepatic veins on ultrasound acute thrombosis is hypoechoic

and associated with the expansion of the 

vessel lumen on color doppler ultrasound no flow seen

in the thrombosed segment 

chronic stage thrombosed hepatic vein results in the formation of a hyperechoic

fibrotic cord 

as seen in this image hepatic vein stenosis is less common than thrombosis.