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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 16  |  Issue : 1  |  Page : 202-205

Imaging of congestive hepatopathy ultrasound and doppler findings


Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra, India

Date of Submission22-Oct-2020
Date of Decision10-Jan-2021
Date of Acceptance08-Feb-2021
Date of Web Publication29-Jul-2021

Correspondence Address:
Dr. Suresh Phatak
Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha - 442 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_381_20

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  Abstract 


Congestive hepatopathy has characteristic features on ultrasound and Doppler imaging; we are presenting the case of a 30-year-old female patient a known case of rheumatic heart disease with severe mitral stenosis with severe tricuspid stenosis with tricuspid regurgitation with congestive cardiac failure and anemia. Important ultrasound and Doppler imaging features are described.

Keywords: Congestive hepatopathy, Doppler, high-resolution ultrasound


How to cite this article:
Unadkat B, Phatak S, Pavanan A, Pattabiraman S. Imaging of congestive hepatopathy ultrasound and doppler findings. J Datta Meghe Inst Med Sci Univ 2021;16:202-5

How to cite this URL:
Unadkat B, Phatak S, Pavanan A, Pattabiraman S. Imaging of congestive hepatopathy ultrasound and doppler findings. J Datta Meghe Inst Med Sci Univ [serial online] 2021 [cited 2021 Sep 16];16:202-5. Available from: http://www.journaldmims.com/text.asp?2021/16/1/202/322636




  Introduction Top


In day to day clinical practice, combined liver and heart dysfunction coexist due to complex cardiohepatic interaction. The effective management of the patients is ensured after identifying the existing interactions between the heart and the liver as it improves the overall prognosis of the disease.[1] The underlying pathophysiology mechanisms consist of increased hepatic vein pressure, reduced hepatic blood flow, and reduced arterial oxygen saturation.[2],[3] Main cardiac conditions that may lead to the development of congestive hepatopathy include valvular heart disease (mitral stenosis and tricuspid regurgitation), cardiomyopathy, left-sided heart failure, and constrictive pericarditis.[4],[5] Congestive hepatopathy refers to hepatic abnormalities that result from passive hepatic venous congestion. Elevated hepatic venous pressure on prolonged exposure may lead to the development of liver fibrosis and cirrhosis. Liver dysfunction and corresponding clinical signs and symptoms typically manifest late in the disease process; recognition of congestive hepatopathy at imaging is critical because advanced liver fibrosis may develop before the condition is suspected clinically.[6] Congestive hepatopathy is usually subclinical.[1] Physical examination is typically dominated by signs of cardiac failure including jugular vein distension, hepatojugular reflux, and peripheral edema. Spider angioma, splenomegaly, and varices are rarely present.[5],[7]


  Case Report Top


A 30-year-old female patient, a known case of rheumatic heart disease with severe mitral stenosis with severe tricuspid stenosis, tricuspid regurgitation, congestive cardiac failure, and anemia, presented with complaints of giddiness and breathlessness which increased on exertion for 3 days and pain in the abdomen and fever for 5 days. She was referred to the radio diagnosis department for a radiograph of the chest and ultrasonography of the abdomen. Radiograph posterioranterior view of the chest revealed massive cardiomegaly [Figure 1]. Abdominal sonography showed mild hepatomegaly with evidence of dilated inferior vena cava (IVC), hepatic veins [Figure 2]a and [Figure 2]b mild splenomegaly, and minimal free fluid in the pelvis. The dilatation of the IVC and the hepatic veins resembles the “playboy Bunny” sign [Figure 3].
Figure 1: X-ray chest posterioranterior view showing cardiomegaly

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Figure 2: (a) Grayscale ultrasound image showing dilated middle hepatic vein (1.4 cm). (b) Grayscale ultrasound image showing dilated inferior vena cava (2.5 cm)

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Figure 3: The dilatation of the inferior vena cava and the hepatic veins resembles the “Playboy Bunny” sign

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Hepatic vein Doppler finding includes highly pulsatile blood flow [Figure 4]. Portal vein Doppler showed abnormal variation in portal flow velocity and pulsatility index of 0.513 [Figure 5]. In hematology investigation, complete blood count revealed hemoglobin value of 5.3 g% with peripheral smear examination showing predominantly normocytic moderately hypochromic red blood cells with mild anisopoikilocytosis showing few microcytes, pencil cells, and teardrop cells. Liver function test examination showed alkaline phosphatase value of 66 IU/L, serum glutamic pyruvic transaminase 17 units/L of serum and serum glutamic-oxaloacetic transaminase 19 units/L of serum, and serum albumin was found to be 2.5 g/dl. Conjugated bilirubin was slightly raised with value of 1.2 mg/dl and unconjugated bilirubin 6.3 g/dl with total bilirubin of 7.5 g/dl.
Figure 4: Portal vein Doppler showed abnormal variation in portal flow velocity and pulsatility index of 0.513

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Figure 5: Hepatic vein Doppler finding includes highly pulsatile blood flow showing a prominent d wave, a retrograde s and a wave

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  Discussion Top


Imaging - for studying hemodynamic properties of the liver in a patient with congestive hepatopathy, the ultrasound is considered the best modality. Findings noted most commonly on ultrasound in a case of hepatopathy consist of dilated IVC and dilated hepatic veins.[8],[9]

The deoxygenated blood to the right atrium is carried by the IVC. Its size and shape strongly relate to the central venous pressure.[10] IVC being compliant, its size varies with change in intravascular pressure; during inspiration, it collapses and during expiration, it dilates. Therefore, we have ranges of accepted diameters for both phases of respiration (0–14 mm in inspiration and 15–20 mm in expiration).[11] The right hepatic vein is normally less than 5.6–6.2 mm in diameter at the origin and dilates in response to elevated venous pressure.[7] The severity of heart failure is correlated to the degree of dilatation of IVC.[7]

During inspiration, the blood flow returning to the heart decreases; therefore, in a normal condition, the IVC and hepatic vein narrow in caliber as resistance to blood flow. When there is increased venous pressure, there is absent or diminished respiratory variation.[9],[12] The dilatation of the IVC and the hepatic veins appears as the “Playboy Bunny” sign.[13],[14] Spectral Doppler ultrasound analysis in case of hepatic congestion may show loss of the normal triphasic hepatic venous waveform due to loss of antegrade venous flow. Dampening of the hepatic venous waveform is due to stiff liver parenchyma in a patient with cirrhosis.[12] In case of tricuspid regurgitation, prominent systolic retrograde pulsation can be seen; the normal portal vein has a steady and continuous waveform.[6] In patients having severe congestive heart failure, there is elevated hepatic venous pressure. This elevated hepatic venous pressure is transmitted through the dilated sinusoids into the portal veins; this results in variation in the portal flow velocity [Figure 4].[12],[15]

Congestive hepatopathy shows characteristic findings on cross-sectional computed tomography (CT) and magnetic resonance (MR) imaging that aid in the diagnosis of congestive hepatopathy. Patchy irregular regions of poor enhancement near the hepatic veins show relatively slow enhancement due to congested hepatic parenchyma. Portal venous phase is best to visualize abnormal enhancement pattern located in the periphery of the liver[16],[17],[18]hyper enhancing hepatic nodule's increased prevalence is a result of chronic passive congestion and it appears similar to that of a focal nodular hyperplasia.[8],[19] CT scan for extrahepatic, bolus transit, and hepatic parenchyma abnormalities shares similarities with contrast-enhanced MR imaging. MR imaging is superior as it provides additional techniques that can be used to evaluate the congested liver. MR angiography and phase-contrast imaging have the added ability to allow the measurement of the velocity and the direction of vascular flow when compared to CT. The transit of the injected contrast material reveals qualitative information regarding vascular flow at CT and MR imaging. MR imaging using contrast such as gadoxetate disodium or gadobenate dimeglumine is able to show hypoenhancing scar clearly during the hepatobiliary phase. High signal intensity at T2-weighted imaging and bands of low signal intensity at precontrast T1-weighted MR imaging corresponds to low attenuating perivascular lymphedema visualized on CT. Fibrosis and cirrhosis of the liver may occur due to prolonged exposure to elevated hepatic venous pressure.

Noninvasive evaluation of liver fibrosis can be done using elastographic techniques. Liver stiffness that relates with the histopathological staging of fibrosis and its content can be measured using elastography.[20] Major determinant that leads to increased liver stiffness includes fibrosis other conditions that can cause increased in liver stiffness include acute hepatitis, acute biliary obstruction, portal hypertension, and passive venous congestion.[21],[22],[23],[24],[25],[26],[27],[28]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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