Heterogeneous Liver Enhancement Research Articles

Magnetic resonance imaging findings in autoimmune hepatitis: how frequent and reproducible are they?

To determine the frequency and interobserver reproducibility of the magnetic resonance imaging (MRI) features considered diagnostic for autoimmune hepatitis. Two abdominal radiologists, blinded to pathology data, reviewed the MRI examinations of 20 patients with autoimmune hepatitis, looking for liver enhancement, lymphadenopathy, portal hypertension, and chronic liver disease. The pattern of liver fibrosis was categorized as reticular, confluent, or mixed. Interobserver agreement was assessed by calculating intraclass correlation coefficients and kappa statistics. The most common abnormal finding on MRI was surface nodularity (in 85%), followed by liver fibrosis with a reticular pattern (in 80%)-categorized as mild (in 25.0%), moderate (in 43.8%), or severe (in 31.2%)-; heterogeneous liver enhancement (in 65%); splenomegaly (in 60%); caudate lobe enlargement (in 50%); and lymphadenopathy (in 40%). The interobserver agreement was almost perfect for surface nodularity (0.83), ascites (0.89), and liver volume (0.95), whereas it was just slight and fair for the degree of fibrosis and for heterogeneous liver enhancement (0.12 and 0.25, respectively). It was also slight and fair for expanded gallbladder fossa and enlarged preportal space (0.14 and 0.36, respectively), both of which are indicative of chronic liver disease. The interobserver agreement was satisfactory for surface nodularity (the most prevalent abnormal MRI finding), ascites, liver volume, and splenomegaly. Conversely, it was only slight or fair for common but less objective criteria.

Prolonged heterogeneous liver enhancement accompanied by abdominal symptoms after sonographic contrast agent injection: a cross-sectional study.

To report the occurrence of abdominal symptoms in patients who presented with prolonged heterogeneous liver enhancement (PHLE) after injecting contrast agent SonoVue®. A total of 105 patients who indicated to have contrast-enhanced ultrasound (CEUS) examinations were consecutively observed. The liver scanning under ultrasound was performed before and after the contrast agent injection. Patients' basic information, clinical manifestations, and ultrasound images under B-mode and CEUS mode were respectively recorded. For patients exhibiting abdominal symptoms, the occurrence and last time of symptoms were recorded in detail. We subsequently compared the difference in clinical characteristics between patients with and without the PHLE phenomenon. In 20 patients with the PHLE phenomenon, 13 showed abdominal symptoms. Eight patients (61.5%) appeared to have mild defecation sensation, and 5 (38.5%) showed apparent abdominal pain. The PHLE phenomenon began to appear within 15 minutes to 1.5 hours after the intravenous injection of SonoVue®. This phenomenon lasted for 30 minutes to 5 hours in ultrasound. Patients with severe abdominal symptoms showed large-area and diffuse PHLE patterns. Only sparse hyperechoic spots in the liver were detected in patients with mild discomfort. Abdominal discomfort resolved spontaneously in all patients. Meanwhile, the PHLE gradually disappeared without any medical treatment. In the PHLE-positive group, the proportion of patients with a history of gastrointestinal disease was significantly higher (P=0.02). Patients with the PHLE phenomenon can exhibit abdominal symptoms. We suggest gastrointestinal disorders may contribute to PHLE, which can be considered a harmless phenomenon that does not affect the safety profile of SonoVue®.

Abdominal Imaging Findings in Patients with COVID-19 Part 2: Solid Organs.

Since severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) first appeared in China in December 2019, the globe has been dealing with an ever-increasing incidence of coronavirus disease 2019 (COVID-19). In addition to respiratory disorders, 40% of patients present with gastrointestinal (GI) involvement. Abdominal pain is the most common indication for computed tomography (CT) and ultrasonography. After GI tract involvement, solid visceral organ infarction is the most prevalent abdominal abnormality in COVID-19. This review aims to gather the available data in the literature about imaging features of solid abdominal organs in patients with COVID-19. Gallbladder wall thickening and distension, cholelithiasis, hyperdense biliary sludge, acalculous cholecystitis, periportal edema, heterogeneous liver enhancement, and liver hypodensity and infarction are among hepatobiliary imaging findings in CT, particularly in patients admitted to ICU. Pancreatic involvement can develop as a result of direct SARS-CoV2 invasion with signs of acute pancreatitis in abdominal CT, such as edema and inflammation of the pancreas. Infarction was the most prevalent renal and splenic involvement in patients with COVID-19 who underwent abdominal CT presenting with areas of parenchymal hypodensity. In conclusion, although solid abdominal organs are rarely affected by COVID-19, clinicians must be familiar with the manifestations since they are associated with the disease severity and poor outcome.

A young man with progressive jaundice and abdominal distension

Budd-Chiari syndrome (BCS) is a rare, life-threatening disease caused by obstruction of hepatic venous outflow. Common presentations are right upper quadrant pain, ascites, and hepatomegaly. A diagnosis of Budd-Chiari syndrome should be suspected when liver disease occurs in a patient with known risk factors for hypercoagulable state. We report a 22-years old transgender man presented with jaundice, marked ascites and hepatomegaly. Imaging studies showed complete thrombosis of all hepatic veins. Finally, he was diagnosed with Budd-Chiari syndrome with antiphospholipid syndrome.
 
 Figure 1 ภาพ CT upper abdomen แสดงให้เห็น marked ascites with heterogeneous liver enhancement, complete obliteration of all hepatic, caudate lobe hypertrophy, small intrahepatic venous collateral และ small arterial enhancing nodules

A Rare Cause of Elevated Liver Tests in a Pregnant Patient

Case: 26-year-old female at 22 weeks gestation with history of anemia presented with nausea, vomiting and sharp, epigastric, non-radiating abdominal pain for 4 days. She denied any bleeding. Surgical and medication history were notable for a previous dilation and curettage and a daily vitamin. Vital signs were normal, physical exam revealed pallor, gravid abdomen with epigastric tenderness to palpation. Hemoglobin was 6.8 g/dL and platelets 84 K/mcL. Liver panel showed AST 87 U/L, ALT 42 U/L and total bilirubin 3.2 mg/dL (direct 0.50 mg/dL). Reticulocytes were 8%, LDH 1142 U/L, haptoglobin undetectable with negative direct antiglobulin test. Peripheral smear showed macrocytosis, thrombocytopenia, anisopoikilocytosis, and no schistocytes. Acute viral hepatitis panel and parvovirus serologies were negative. Doppler ultrasound showed splenomegaly, normal fetus and liver with near occlusive thrombus of the middle hepatic vein with reversal of flow in the right portal vein. CT abdomen/pelvis revealed heterogeneous enhancement of liver with filling defects in multiple hepatic veins suggestive of thrombi. ADAMST13 level, protein C and S, antithrombin, glucose-6-phosphate dehydrogenase levels, factor V Leiden, Beta-2 glycoprotein, ANA, ASMA, SPEP and AMA were all negative. Endoscopy was negative for portal hypertensive gastropathy or varices. Duodenal biopsies were normal. Flow cytometry showed PNH clone percent of 84% in granulocytes, 68% in monocytes, and type III RBC (complete CD59 deficiency) of 8% confirming diagnosis of PNH. The patient was transfused, started on anticoagulation and eculizumab. Her anemia improved and she delivered a healthy, full-term baby. Discussion: PNH is characterized by a triad of intravascular hemolysis, thrombosis and bone marrow failure. Thrombosis occurring in atypical locations should prompt consideration of PNH. The hepatic vein is the most frequently involved vessel. PNH is associated with increased fetomaternal morbidity and mortality and thrombosis is the leading cause of death. Unexplained hemolytic anemia in a pregnant patient with concomitant abnormal liver tests may initially evoke diagnosis of HELLP (hemolysis, elevated liver enzymes, and low platelets), however, management of the two condition differs vastly. Anticoagulation is recommended for pregnant women with PNH thrombosis unless contradicted.Eculizumab reduces the risk of thrombosis. BMT is the only curative therapy for PNH with success rates of up to 100%.

A Rare Case of Budd Chiari Syndrome in a Child

A 7-year- old male child presented with the complaints of tense abdominal distension and swelling over feet since 1 month. The patient had repeated episodes of similar complaints since last two years with partial or complete relief after taking various forms of allopathic therapy. On imaging, Budd-Chiari syndrome was diagnosed which was hallmarked by occluded Inferior venacava (IVC), caudate lobe enlargement and heterogeneous liver enhancement. Initially thrombolysis done leading to complete remission for the patient for 15 days, later on again the patient developed similar complaints for which balloon venoplasty and hepatic vein stenting was done.

Leiomyosarcoma of inferior vena cava with intracardiac extension presenting as Budd-Chiari syndrome: Report of a rare case

Primary leiomyosarcoma of vascular origin is a rare malignant smooth muscle tumor. This report describes a case of primary leiomyosarcoma of the inferior vena cava (IVC) in a 52-year-old male who presented with complaints of abdominal pain, chest pain, and bilateral lower limb swelling for 4 months. Imaging of the chest and abdomen revealed a mass in the IVC extending into right atrium, heterogeneous enhancement of liver, hepatosplenomegaly, and ascites. Histopathological examination showed a malignant spindle cell tumor with cells arranged in fascicular and hemangiopericytomatous pattern. Immunohistochemistry for smooth muscle actin and desmin confirmed smooth muscle origin of the tumor. Recognition of this tumor in this rare location and Budd-Chiari syndrome-like presentation is imperative for proper management of the patient.

Letter to the editor: prolonged heterogeneous liver enhancement on contrast-enhanced ultrasound.

Letter to the editor: prolonged heterogeneous liver enhancement on contrast-enhanced ultrasound.

Budd-Chiari Syndrome Caused by TIPS Malposition: A Case Report.

Budd-Chiari syndrome refers to hepatic pathology secondary to diminished venous outflow, most commonly associated with venothrombotic disease. Clinically, patients with Budd-Chiari present with hepatomegaly, ascites, abdominal distension, and pain. On imaging, Budd-Chiari syndrome is hallmarked by occluded IVC and or hepatic veins, caudate lobe enlargement, heterogeneous liver enhancement, intrahepatic collaterals, and hypervascular nodules. Etiopathological factors for Budd-Chiari syndrome include several systemic thrombotic and nonthrombotic conditions that can cause venous outflow obstruction at hepatic veins and/or IVC. While the transjugular intrahepatic portosystemic shunt (TIPS) is used as a treatment option for Budd-Chiari syndrome, Budd-Chiari syndrome is not a well-known complication of TIPS procedure. We report a case of Budd-Chiari syndrome that occurred in a transplanted cirrhotic liver from malpositioned proximal portion of the TIPS in IVC causing occlusion of the ostia of hepatic veins which was subsequently diagnosed on contrast-enhanced CT.

Prolonged Heterogeneous Liver Enhancement on Contrast-Enhanced Ultrasound

Prolonged heterogeneous liver enhancement (PHLE) is a rare phenomenon that is similar to the ultrasound findings of portal venous gas. The purpose of this report is to describe the phenomenon of PHLE after the injection of the ultrasound contrast agent SonoVue(®). From 2000 to 2013, 13 patients with PHLE ("cloudy", "wool-like") after bolus injection of SonoVue(®) were observed. The height, weight, and body mass index (BMI) of the patients, and the number of injections were analyzed. In addition, the literature was reviewed. The phenomenon occurred as early as 2 minutes after bolus contrast administration and lasted up to 5 hours on both B-mode and contrast-specific ultrasound. 8/13 (62 %) patients received two or more boluses. None of the patients experienced SonoVue(®)-related side effects or health problems. The phenomenon was not reproducible in 3 patients who received a second SonoVue(®) injection 24 hours after receiving the first. This phenomenon is more likely to occur in patients who receive high-dose (or multiple) injections of UCA. It may occur as early as 2 minutes after contrast administration, and therefore, may affect the evaluation of focal liver lesions in the late phase. This phenomenon should not be misdiagnosed as a pathological finding of the liver.

Hepatic Failure and Death due to New Onset T Cell Lymphoma

Liver involvement is commonly seen in disseminated T cell lymphoma; however, it is rarely the presenting organ. Here, we describe a case of T cell lymphoma presenting as acute hepatobiliary disease leading to hepatic failure and death. Forty-seven-year-old male with history of cirrhosis (etiology undetermined), diabetes mellitus, and pancytopenia was admitted to ICU for hypotension and failure to thrive. He had icterus, minimal ascitis, and hepatosplenomegaly on physical examination. No lymphadenopathy was noted. Laboratory workup on admission showed elevated total bilirubin (10.1mg/dl) and liver enzymes. Serology for acute viral hepatitis, human immunodeficiency virus, Epstein-Barr virus, and autoimmune hepatitis was negative. CT abdomen showed cirrhotic liver with heterogeneous arterial enhancement of the liver without definite mass lesions. Hospital course was complicated by progressively worsening hypotension, respiratory failure, profound acidosis, disseminated intravascular coagulation, and multi-organ system failure leading to death on hospital day12. Autopsy of the liver showed cirrhotic changes with infiltration with atypical small lymphocytes confined to septa which were CD3 and CD5 positive (CD4 weakly positive, CD8, CD20, CD57, CD56, CD30, Alk-1, granzyme B, TIA1, and S100 negative). Unusual clinical/histological features include (1) initial clinical presentation of hepatic dysfunction without obvious physical signs of lymphoma, (2) negative workup for viral, toxic, autoimmune, and metabolic liver disease, (3) involvement of the entire liver, observed as heterogeneous enhancement of liver without any focal mass lesion as seen on CT scan, (4) an aggressive nature of disease, and (5) autopsy of liver with T cell infiltration confined to septa. Initial diagnosis was challenging due to unusual clinical presentation suggesting inflammatory hepatobiliary disease and the absence of enlarged lymph nodes. In conclusion, early suspicion of this aggressive lymphoma is important and should be considered in the evaluation of a patient whose course is atypical for hepatitis. Even in the absence of a mass lesion or lymphadenopathy, hepatosplenic T cell lymphoma should be included in the differential diagnosis of acute hepatic dysfunction in a patient who has no evidence of viral, toxic, autoimmune, or metabolic liver disease.

Doppler Waveform Pattern Changes in a Patient with Primary Budd-Chiari Syndrome before and after Angioplasty

A 34-year-old woman was admitted for treatment of esophageal varices. Seven years earlier, she had been diagnosed with Budd-Chiari syndrome, and percutaneous transluminal angioplasty (PTA) for right hepatic vein (RHV) stenosis was done. On admission, Doppler sonography showed a flat waveform in the RHV. RHV re-stenosis was confirmed on X-ray sonography. After PTA, the stenosis improved. Heterogeneous liver enhancement on enhanced computed tomography became homogeneous, her esophageal varices became inconspicuous, and the flat Doppler waveform pattern changed to a triphasic pattern. Doppler sonography was very useful for evaluating the effect of angioplasty and to diagnose re-stenosis.

MR Imaging Findings in Autoimmune Hepatitis: Correlation with Clinical Staging

To retrospectively evaluate the morphologic and enhancement features of the liver on magnetic resonance (MR) images obtained in patients with autoimmune hepatitis (AIH) and to determine if there is a correlation between MR imaging findings and severity of clinical disease as measured with the Mayo end-stage liver disease (MELD) score. This study was compliant with the Health Insurance Portability and Accountability Act and approved by the institutional review board. The need for informed consent was waived. Thirty-two patients (29 female and three male patients; mean age, 44 years; age range, 14-69 years) undergoing treatment for AIH underwent unenhanced and gadolinium-enhanced MR imaging. Two radiologists reviewed all cases independently to determine the presence of patchy or heterogeneous liver enhancement, biliary duct changes, lymphadenopathy, and findings of portal hypertension. Fibrosis was graded as mild, moderate, or severe reticular (corresponding to a grading scale of 1-3) or as confluent. Agreement between radiologists was assessed by using kappa coefficients. Mean MELD scores were compared across fibrosis categories by using the Kruskal-Wallis analysis of variance. Of the 32 patients, two (6%) had no imaging findings of cirrhosis. Thirty patients (94%) had reticular fibrosis with a mean grade of 1.8. Six patients had confluent fibrosis, and all six had associated reticular fibrosis. Mild intrahepatic biliary duct dilatation involving the right and left lobes was observed in four patients (12%). Lymphadenopathy was observed in 12% of patients. None of the patients had hepatocellular carcinoma. There was no significant overall association between fibrosis grade and MELD score (P = .36). Although fibrosis is a common feature in AIH and is often moderate to severe, no significant correlation between fibrosis grade and MELD score was found.