Passive Hepatic Congestion

 Early retrograde enhancement of dilated inferior vena cava (IVC) and hepatic veins (HVs)


image Heterogeneous, mottled, reticulated, mosaic hepatic parenchymal pattern

image Periportal low attenuation (perivascular lymphedema)

image Hepatomegaly and ascites


• US: Loss of normal triphasic flow pattern
image Spectral signal may have “M” shape

image Cardiac cirrhosis: Flattening of Doppler wave form in hepatic veins

image “To and fro” motion in hepatic veins and IVC




TOP DIFFERENTIAL DIAGNOSES




• Budd-Chiari syndrome

• Hepatic cirrhosis

• Acute viral hepatitis


CLINICAL ISSUES




• Passive hepatic congestion usually secondary to
image Congestive heart failure

image Constrictive pericarditis

image Tricuspid insufficiency

image Right heart failure

• Radiologists may be 1st to recognize cardiac source of liver disease

• Diagnosis is based on clinical and imaging findings


DIAGNOSTIC CHECKLIST




• Differentiate acute passive hepatic congestion from Budd-Chiari and viral hepatitis

• Distinguish chronic, cardiac cirrhosis from other etiologies

image
(Left) Graphic shows massive diffuse dilatation of the hepatic veins and mildly heterogeneous liver parenchyma due to passive congestion of the liver.


image
(Right) Axial CECT in the arterial phase shows early retrograde opacification of dilated hepatic veins image and the inferior vena cava (IVC) due to reflux of injected contrast medium through the heart, a sign of impaired antegrade hepatic venous drainage.

image
(Left) Increased pulsatility of portal vein Doppler signal image is demonstrated in this patient with passive hepatic congestion secondary to tricuspid insufficiency.


image
(Right) Transverse ultrasound shows dilated hepatic veins image and IVC in a patient with passive hepatic congestion.


TERMINOLOGY


Synonyms




• Congested liver in cardiac disease


Definitions




• Stasis of blood within liver parenchyma as result of impaired hepatic venous drainage


IMAGING


General Features




• Best diagnostic clue
image Dilated hepatic veins with “to and fro” blood flow on color Doppler US

• Key concepts
image Hepatic manifestations of cardiac disease
– Acute manifestation: Enlarged, heterogeneous liver

– Late manifestation: Cardiac cirrhosis, small liver that may resemble cirrhosis of other causes

image Passive hepatic congestion usually secondary to
– Congestive heart failure (CHF)

– Constrictive pericarditis

– Tricuspid insufficiency

– Right heart failure (e.g., pulmonary artery obstruction caused by lung cancer)

image Characteristic sign on physical exam
– Hepatojugular reflux


CT Findings




• Early retrograde enhancement of dilated inferior vena cava (IVC) and hepatic veins (HVs)
image Due to contrast reflux from right atrium into IVC

• Heterogeneous, mottled hepatic parenchymal pattern on arterial &/or venous phase CECT
image Due to delayed enhancement of smaller hepatic veins

• Peripheral, large, patchy areas of poor or delayed enhancement

• Periportal low attenuation (perivascular lymphedema)
image Decreased attenuation around intrahepatic IVC

• Hepatomegaly and ascites

• Chest findings vary by type of cardiac disease
image Small heart due to constrictive pericarditis

image Cardiomegaly due to valvular heart disease or cardiomyopathy

image ± pericardial or pleural effusions


MR Findings




• T2WI
image Periportal high signal intensity (periportal edema)

• T1WI C+
image Same dilated IVC and HVs as seen on CECT

image Mottled hepatic enhancement

• MRA
image Slow or absent antegrade flow within IVC

Nov 16, 2016 | Posted by in GASTROINTESTINAL IMAGING | Comments Off on Passive Hepatic Congestion

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