Chronic hepatitis B can cause hepatocellular carcinoma without cirrhosis
• Multiphasic CECT & /or MR is mandatory for hepatocellular carcinoma surveillance among cirrhotic patients
TOP DIFFERENTIAL DIAGNOSES
• Steatosis, steatohepatitis
• Hepatitis, autoimmune
• Hepatic injury from toxins
• Passive hepatic congestion
CLINICAL ISSUES
• New combination of protease inhibitor (simeprevir) and nucleotide polymerase inhibitor (sofosbuvir) holds real promise for cure of many patients with hepatitis C virus
DIAGNOSTIC CHECKLIST
• Multiphasic MR with elastography is best single test for evaluation of patients with chronic hepatitis and cirrhosis
(Left) H&E demonstrates lymphocytes passing beyond the limiting plate and surrounding hepatocytes. Mild hepatocyte swelling and necrosis are often evident, reflecting the resultant hepatocyte injury. (Courtesy L. Yerian, MD.)
(Right) Longitudinal ultrasound in a patient with acute viral hepatitis shows a markedly thickened gallbladder wall , but no calculi. Acute hepatitis generally causes more impressive gallbladder wall edema than does acute cholecystitis.
(Left) Axial CECT in the same patient with acute viral hepatitis shows hepatomegaly, periportal edema , and porta hepatis lymphadenopathy .
(Right) Axial CECT in the same patient shows massive gallbladder wall thickening and a small amount of ascites . There is nothing specific about these findings to indicate the exact etiology of this case of hepatitis. Imaging helps to exclude other causes of acute abdominal pain and liver disfunction, such as biliary obstruction.
TERMINOLOGY
Abbreviations
• Hepatitis B virus (HBV)
• Hepatitis C virus (HCV)
• Epstein-Barr virus (EBV)
Definitions
• Acute hepatitis: Hepatocyte necrosis and inflammation resulting from acute viral infection
IMAGING
General Features
• Best diagnostic clue
Acute hepatitis: Hepatomegaly, periportal and gallbladder wall edema in acutely ill patient
• Size
Acute: Enlarged, homogeneous liver
Chronic: Small, heterogeneous, nodular liver
• Morphology
Micronodular cirrhosis
• Other general features
In medical practice, hepatitis usually refers to viral infection
– Hepatitis B and C are major variants
Role of imaging in cases of viral hepatitis
– Try to exclude biliary obstruction or neoplasm
– Evaluate parenchymal damage noninvasively
CT Findings
• CECT
Acute viral hepatitis
– Hepatomegaly, gallbladder wall thickening
– Periportal hypodensity (fluid, lymphedema)
– Acute viral hepatitis rarely causes diffuse hypoattenuation of liver
Unlike acute alcoholic or nonalcoholic steatohepatitis
– Fulminant hepatic failure
Focal or global volume loss of liver, diffuse hepatocellular necrosis (low density) + ascites on imaging
Can develop acutely, subacutely, or in setting of cirrhosis
Often manifested by hepatic encephalopathy
Usually due to coexisting hepatic injury (e.g., alcohol, other viral infection) or following variceal hemorrhage or sepsis in patient with cirrhosis
Chronic active hepatitis
– Lymphadenopathy in porta hepatis, gastrohepatic ligament, and retroperitoneum (in 65% of cases)
– Hyperdense, small regenerating nodules within liver (better seen on NECT than CECT)
Regenerating nodules may be isodense with liver on CECT
Cirrhosis
– Volume loss, especially in medial and anterior segments of liver
– Signs of portal hypertension
Splenomegaly, ascites, varices
– Increased risk of hepatocellular carcinoma (HCC)
MR Findings
• Viral hepatitis
Increase in T1 and T2 relaxation times of liver
T2WI: High signal intensity bands paralleling portal vessels (periportal edema and fibrosis)
MR elastography provides noninvasive measure of extent of liver fibrosis
– Correlates well with progression of disease or response to treatment
Ultrasonographic Findings
• Grayscale ultrasound
Acute viral hepatitis
– ↑ in liver and spleen size, ↓ echogenicity of liver
– “Starry sky” appearance: Increased echogenicity of portal venous walls
– Periportal hypo-/anechoic area (hydropic swelling of hepatocytes)
– Thickening of gallbladder wall
Chronic viral hepatitis, cirrhosis
– Increased echogenicity of liver and coarsening of parenchymal texture
– “Silhouetting” of portal vein walls (loss of definition of portal veins)
– Adenopathy in porta hepatis
Imaging Recommendations
• Best imaging tool
US usually sufficient to suggest diagnosis of acute viral hepatitis
– Diagnosis is established by clinical exam, serology ± liver biopsy
US may be sufficient for imaging surveillance of patients with hepatitis C
– Prior to development of heterogeneous, nodular, fibrotic, cirrhotic liver
– US has poor sensitivity and specificity for detection of HCC in cirrhotic liver
Multiphasic CECT & /or MR is mandatory for HCC surveillance among cirrhotic patients
Only gold members can continue reading. Log In or Register to continue
, but no calculi. Acute hepatitis generally causes more impressive gallbladder wall edema than does acute cholecystitis.
, and porta hepatis lymphadenopathy 
.
and a small amount of ascites 
. There is nothing specific about these findings to indicate the exact etiology of this case of hepatitis. Imaging helps to exclude other causes of acute abdominal pain and liver disfunction, such as biliary obstruction.
US may be sufficient for imaging surveillance of patients with hepatitis C
