Hyperdense on NECT, isodense on CECT

image Hypointense on T2 and GRE MR

image 3-10 mm in size

• Vascular derangements
image Arterioportal and portovenous shunts

image Varices (gastroesophageal, caput medusae, etc.)

• Fibrosis: Diffuse, lace-like, thick, or confluent foci
image Hypointense on T1W; hyperintense on T2W MR

• Cirrhosis-induced hepatocellular carcinoma (HCC)
image Heterogeneous enhancement on arterial phase; usually hypodense on venous and delayed phase CT + MR

image Hyperintense on T2W MR

image Bright on DWI MR

image ± capsule, fat, venous invasion, metastases


• Treated liver metastases or lymphoma

• Budd-Chiari syndrome

• Hepatic sarcoidosis

• Primary portal vein thrombosis

• Nodular regenerative hyperplasia


• MR has advantage in detection and characterization of focal nodules within cirrhotic liver

(Left) Graphic shows a cirrhotic liver with a nodular surface contour and an increase in the caudate to right lobe ratio, measured from the branch point of the right portal vein image to the edges of the caudate and right lobes, respectively. Note the bands of fibrosis image and ascites.

(Right) Axial CECT shows a cirrhotic liver and large varices image. Note the enlarged caudate lobe image, which is as wide as the right lobe, although the caudate lobe is normally no more than 60% of the width of the right lobe.

(Left) Axial NECT in this 50-year-old woman with primary biliary cirrhosis shows innumerable small hyperdense regenerative nodules image, surrounded by lace-like fibrosis.

(Right) The nodules disappear into the background cirrhotic liver on this CECT from the same patient. Prominent porta hepatis lymphadenopathy image, another typical feature of primary biliary cirrhosis, is also noted. Primary biliary cirrhosis is an autoimmune disease that typically affects women in their 5th or 6th decade.



• Chronic liver disease characterized by diffuse parenchymal injury, extensive fibrosis, and conversion of liver architecture into structurally abnormal nodules


General Features

• Best diagnostic clue
image Nodular contour, widened fissures, and enlarged caudate lobe with ascites, splenomegaly, and varices

• Size
image Moderate to advanced cirrhosis: Decreased size
– Earlier disease: May be enlarged

– Especially in primary biliary cirrhosis

• Key concepts
image Common end response of liver to variety of insults and injuries

image Classification by morphology (not very useful)
– Micronodular (Laennec) cirrhosis
image Usually due to alcoholism

– Macronodular (postnecrotic) cirrhosis
image Usually viral hepatitis

image Classification by etiology and severity more useful

CT Findings

• Atrophy of right lobe and medial segment of left lobe

• Enlarged caudate lobe and lateral segment of left lobe
image Caudate: Right lobe ratio often > 1.0 in cirrhosis

image Caudate is normally < 60% width of right lobe

• Widened fissures between segments/lobes

• Deep gallbladder (GB) fossa
image GB often lies against anterolateral abdominal wall

• Vascular derangements
image Varices (gastroesophageal, caput medusae, etc.)

image Arterioportal and portovenous shunts
– Arterioportal (AP) shunts are usually peripheral, wedge-shaped, small; seen only on arterial phase

– Small AP shunt difficult to distinguish from very small hepatocellular carcinoma (HCC)
image Follow-up imaging (CT or MR) in 3-6 months is sufficient for surveillance

image “Corkscrew” hepatic arterial branches
– Enlarged and displaced around regenerative nodules

• Splenomegaly

• Nodular liver contour (not apparent in all)

• Siderotic regenerative nodules
image Hyperdense on NECT, isodense on CECT

image Most regenerative nodules are not detected by CT

• Fibrotic and fatty changes
image Fibrosis: Diffuse, lace-like, thick bands or confluent “masses”
– More apparent on NECT (hypodense)

– May show persistent enhancement on delayed CECT (or contrast-enhanced MR)
image Distinguishes from HCC, which shows washout on delayed imaging

image Fatty changes: Diffuse or geographic areas of low attenuation
– Usually limited to alcoholic hepatitis with early cirrhosis

• Peribiliary cysts
image Cystic dilation of peribiliary gland in wall of large bile ducts

image Range in size from 2 mm to 2 cm

image Resemble string of pearls or grapes on a stem

• Cirrhosis-induced HCC
image NECT: Hypodense or heterogeneous, ± fat

image CECT
– Heterogeneous enhancement on arterial phase; usually iso- to hypodense on venous and delayed phase scans

– ± capsule, portal or hepatic venous invasion, metastases

MR Findings

• Siderotic regenerative nodules: Paramagnetic effect of iron within nodules
image T1WI: Hypointense

image T2WI: Increased conspicuity of low signal intensity

image T2 gradient-echo and fast low-angle shot (FLASH) images
– Markedly hypointense (best sequence for detection)

image Gamna-Gandy bodies (siderotic nodules in spleen)
– T1WI and T2WI: Hypointense

• Dysplastic regenerative nodules
image T1WI: Hyperintense; T2WI: Hypointense
– Opposite to usual pattern for HCC

image Minimal vascularity

image Take up and retain hepatobiliary MR contrast agents on delayed phase
– Most specific test to distinguish from HCC

• HCC nodule
image T1WI: Iso-, hypo-, or hyperintense

image T2WI: Hyperintense

image T1 C+: Increased enhancement on arterial phase
– Washes out to hypointense on venous and delayed phases

image Diffusion-weighted imaging
– Restricted diffusion (bright signal) within HCC

image Rarely take up or retain hepatobiliary MR contrast agents

• Fibrotic and fatty changes
image T1WI: Fibrosis = hypointense; fat = hyperintense

image T2WI: Fibrosis = hyperintense; fat = hypointense

• MR elastography
image Shows promise in noninvasive evaluation of extent of liver fibrosis

Ultrasonographic Findings

• Grayscale ultrasound
image Nodular liver contour and parenchyma

image Increased and coarsened liver echogenicity
– Decreased visualization of deep liver

image Atrophy of right lobe and medial segment of left lobe

image Features of portal hypertension
– Increased pulsatility of portal vein Doppler tracing

– Dilated hepatic and splenic arteries with increased flow

• Color Doppler
image Used to determine portal vein patency and direction of flow
– Hepatopetal is normal

– Hepatofugal is sign of severe portal hypertension

• Ultrasound is of most value and accuracy in screening patients with less advanced chronic liver disease
image Less accurate in detecting or characterizing nodules within cirrhotic liver

image Presence of fibrosis, fat, regenerative nodules makes detection of HCC very difficult

Imaging Recommendations

• Best imaging tool
image Multiphasic CT or MR

• Protocol advice
image US is suitable for screening until cirrhosis is established

image CECT is preferable in acutely ill patients or those with ascites

image MR is preferable in alcoholic cirrhosis and for detection/distinction of hepatic nodules
– Include delayed phase MR or CT (5-10 minutes)

– Hepatobiliary MR contrast agents may aid in detection of HCC
image Gadoxetate (Eovist, Primovist) is retained in normal liver, variably in cirrhotic liver, rarely in HCC


Treated Liver Metastases or Lymphoma

• Simulates nodules, fibrosis, volume loss of cirrhotic liver

• Breast carcinoma metastases to liver
image May result in “pseudocirrhosis,” especially after treatment

Nov 16, 2016 | Posted by in GASTROINTESTINAL IMAGING | Comments Off on Cirrhosis

Full access? Get Clinical Tree

Get Clinical Tree app for offline access