Nazleen Bharmal

Gillian Lieberman, MD

March 2002

Cirrhosis & Portal Hypertension:

Radiologic Findings

Nazleen Bharmal
Harvard Medical School Year III
Gillian Lieberman, MD

Nazleen Bharmal
Gillian Lieberman, MD

Our Patient
HPI 50 year-old male presents with confusion
PMH alcoholism, s/p cholecystectomy
PE jaundice, positive abdominal fluid wave
Labs Abnormal LFTs: nl aminotransferases,
TBili, PT, Alb, Ammonia, Alk Phos
Impression Alcoholic cirrhosis, Hepatic
encephalopathy
2

Nazleen Bharmal
Gillian Lieberman, MD

Menu of Tests
Ultrasound (US)
Computed tomography (CT)
Magnetic resonance imaging (MRI)
Nuclear medicine
3

Nazleen Bharmal
Gillian Lieberman, MD

Our Patient: US Imaging

Ultrasound of Liver
Ascites
Liver

Doppler studies: patent

portal & hepatic veins
courtesy of BIDMC PACS

Nazleen Bharmal
Gillian Lieberman, MD

Differential Diagnosis:
Hepatic Ascites*
Sinusoidal

Post-Sinusoidal

Pre-Sinusoidal

Cirrhosis (81%)

Constrictive pericarditis

Portal or Splenic

SBP

Right-sided CHF

Hepatitis

Tricuspid insufficiency

Liver Metastases

Budd-Chiari syndrome

HCC

Veno-occlusive disease

vein thrombosis
Schistosomiasis

* Portal Hypertension-Related Etiologies

5

Nazleen Bharmal
Gillian Lieberman, MD

Hepatic Anatomy

Sullivan, Lisa. The Liver, Biliary System, and Pancreas. Juhl: Paul and Juhl's
Essentials of Radiologic Imaging, 7th ed., Lippincott Williams & Wilkins, 1998.

Nazleen Bharmal
Gillian Lieberman, MD

CT Abdomen: Normal
Patient 1

Stomach

Liver
Aorta

Spleen

CT Abdomen with IV contrast

courtesy of BIDMC PACS

Nazleen Bharmal
Gillian Lieberman, MD

Our Patient: CT Imaging

CT Abdomen with IV contrast
Falciform ligament
?
Nodular Liver

Stomach

Ascites

Spleen

courtesy of BIDMC PACS

Nazleen Bharmal
Gillian Lieberman, MD

Our Patient: Diagnosis

Liver Cirrhosis
LIVER
CIRRHOSIS

Portal Hypertension
Ascites, Varices,
Splenomegaly,
Encephalopathy
Netter, F.H. The CIBA Collection of Medical Illustrations,
Volume 3: Digestive System, Part III, 1957

Nazleen Bharmal
Gillian Lieberman, MD

Portal
Hypertension
Signs &
Symptoms

Netter, F.H. The CIBA Collection of

Medical Illustrations, Volume 3:
Digestive System, Part III, 1957

10

Nazleen Bharmal
Gillian Lieberman, MD

Portal
System:
Portacaval
Anastomoses

Netter, F.H. The CIBA Collection of

Medical Illustrations, Volume 3:
Digestive System, Part III, 1957

11

Nazleen Bharmal
Gillian Lieberman, MD

Esophageal Varices
Our Patient

CT Abdomen with IV contrast

courtesy of BIDMC PACS

12

Nazleen Bharmal
Gillian Lieberman, MD

Esophageal Varices: Another Look

Normal
Anatomy

Abnormal
Anatomy

Netter, F.H. The CIBA Collection of Medical Illustrations, Volume 3: Digestive System, Part I, 1957

13

Nazleen Bharmal
Gillian Lieberman, MD

Esophageal Varices: Barium Study

Normal

http://mycourses.me
d.harvard.edu/collec
tion_display.asp?tas
k=framer&tn=y&lo
okupGUID=Head{0
193EB25-85474D1D-BE9E31E85A142F65}

Abnormal

http://mycourses.med
.harvard.edu/collectio
n_display.asp?task=fr
amer&tn=y&lookup
GUID=Head{33ACA
E5C-C5E8-4D1FA23F626B72EBF9DC}

14

Nazleen Bharmal
Gillian Lieberman, MD

Esophageal Varices: Endoscopy

Normal

Abnormal

http://medlib.med.utah.edu/WebPath/GIHT
ML/GI121.hmtl

http://home.t-online.de/home/afreytag/o06e.htm

15

Nazleen Bharmal
Gillian Lieberman, MD

CT Abdomen: Normal
Patient 1

Stomach

Liver
Aorta

Spleen

CT Abdomen with IV contrast

courtesy of BIDMC PACS

16

Nazleen Bharmal
Gillian Lieberman, MD

Gastric Varices
Our Patient

CT Abdomen with IV contrast

courtesy of BIDMC PACS

17

Nazleen Bharmal
Gillian Lieberman, MD

More Varices Spleen & Bowel

Our Patient

CT Abdomen with IV contrast

courtesy of BIDMC PACS

18

Nazleen Bharmal
Gillian Lieberman, MD

Splenomegaly
Patient 2

Patient 3
Ascites
Ascites

Anasarca

CT Abdomen w/ IV contrast
courtesy of BIDMC PACS

MR Abdomen T2 Coronal
19

Nazleen Bharmal
Gillian Lieberman, MD

One More Finding

Our Male Patient
Gynecomastia

Gynecomastia

CT Abdomen without IV contrast

courtesy of BIDMC PACS

20

Nazleen Bharmal
Gillian Lieberman, MD

Our Patient: Course

High risk for UGIB and HCC
Intractable Ascites TIPS procedure
Liver Transplant
21

Nazleen Bharmal
Gillian Lieberman, MD

TIPS Procedure
Our Patient

Angiogram

TIPS stent with contrast

demonstrates flow from
portal vein to IVC, thus
bypassing the liver

courtesy of BIDMC PACS

22

Nazleen Bharmal
Gillian Lieberman, MD

TIPS Procedure: US Imaging

Our Patient
Liver Ultrasound
Ascites
Liver
Stent

courtesy of BIDMC PACS

23

Nazleen Bharmal
Gillian Lieberman, MD

TIPS Procedure: Color Doppler US

Liver Ultrasound

Our Patient

Patent TIPS
Red = flow
towards transducer
Blue = flow away
from transducer

courtesy of BIDMC PACS

24

Nazleen Bharmal
Gillian Lieberman, MD

The TIPS procedure relieved the

ascites somewhat. Our patient
went on to receive a liver
transplant.

25

Nazleen Bharmal
Gillian Lieberman, MD

References
Netter, F.H. The CIBA Collection of Medical Illustrations, Volume 3: Digestive System, Part
III. CIBA-Geigy, Summit, 1957
Netter, F.H. The CIBA Collection of Medical Illustrations, Volume 3: Digestive System, Part I.
CIBA-Geigy, Summit, 1957
Sabatine, Marc S., MD editor. Pocket Medicine. Lippincott Williams & Wilkins. Philadelphia:
2000. 3-20, 3-22.
Gamuts, Radiology Texts, UptoDateonline
Sullivan, Lisa. The Liver, Biliary System, and Pancreas. Juhl: Paul and Juhl's Essentials of
Radiologic Imaging, 7th ed., Lippincott Williams & Wilkins, 1998, pgs 511-514.
Brown JJ, Naylor MJ, Yagan N. Imaging of Hepatic Cirrhosis. Radiology 202:1-13, 1997.
Taylor HM, Ros PR. Hepatic Imaging. Radiologic Clinics of North America 36(2):237-44, March
1998.
Portal Hypertension. The Merch Manual Section 4:Chapter 38, Merck & Co, Inc. New
Jersey:2001
26

Nazleen Bharmal
Gillian Lieberman, MD

Acknowledgements
Pamela Lepkowski
Gillian Lieberman, MD
Daniel Saurbour, MD
Haldon Bryer, MD
Ravi Thakur, MD
Larry Barbaras and Cara Lyn Damour
27