Cirrhosis other imaging findings: Difference between revisions
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==Overview== | ==Overview== | ||
[[Tc-99m]] labeled sulfur can be used in nuclear imaging to obtain an indication of hepatic function. When assessing a patient for a [[liver transplant]], a [[CTA]] is used to asses the drainage of the liver. | [[Tc-99m]] labeled sulfur can be used in nuclear imaging to obtain an indication of hepatic function. When assessing a patient for a [[liver transplant]], a [[CTA]] is used to asses the drainage of the liver. | ||
All patients with cirrhosis should undergo a diagnostic [[endoscopy]] for the evaluation of [[varices]]. Gastric endoscopy is also an option if gastric varices are suspected, and endoscopic ultrasound can also help in the visualization of varices. [[ERCP]] can be done if biliary pathology as a cause of the cirrhosis is suspected. | |||
==Other Imaging Findings== | ==Other Imaging Findings== | ||
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===Endoscopy=== | ===Endoscopy=== | ||
[[Image:Esophageal varices.jpg|thumb|200px|left|Esophageal varices as seen on Endoscopy]] | [[Image:Esophageal varices.jpg|thumb|200px|left|Esophageal varices as seen on Endoscopy]] | ||
All patients with cirrhosis should undergo a diagnostic endoscopy to document the presence or absence of varices and to determine their risk for variceal hemorrhage. <ref name="pmid17879356">{{cite journal |author=Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W |title=Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis |journal=[[Hepatology (Baltimore, Md.)]] |volume=46 |issue=3 |pages=922–38 |year=2007 |month=September |pmid=17879356 |doi=10.1002/hep.21907 |url=http://dx.doi.org/10.1002/hep.21907 |accessdate=2012-09-06}}</ref> Esophageal varices are dilated collaterals in the lower esophagus that interconnect portal and systemic circulation in patients with [[portal hypertension]]. Endoscopically, esophageal varices are usually unmistakable and appear as irregular, serpiginous, bluish structures running longitudinally in the submucosa of the esophageal wall. Occasionally, it can be difficult to differentiate small varices from esophageal folds and EUS can be helpful. The presence of varices in patients with cirrhosis is also an independent risk factor for survival.<ref name="pmid6969201">{{cite journal |author=Lebrec D, De Fleury P, Rueff B, Nahum H, Benhamou JP |title=Portal hypertension, size of esophageal varices, and risk of gastrointestinal bleeding in alcoholic cirrhosis |journal=[[Gastroenterology]] |volume=79 |issue=6 |pages=1139–44 |year=1980 |month=December |pmid=6969201 |doi= |url= |accessdate=2012-09-07}}</ref> | All patients with cirrhosis should undergo a diagnostic endoscopy to document the presence or absence of varices and to determine their risk for variceal hemorrhage. <ref name="pmid17879356">{{cite journal |author=Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W |title=Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis |journal=[[Hepatology (Baltimore, Md.)]] |volume=46 |issue=3 |pages=922–38 |year=2007 |month=September |pmid=17879356 |doi=10.1002/hep.21907 |url=http://dx.doi.org/10.1002/hep.21907 |accessdate=2012-09-06}}</ref> Esophageal varices are dilated collaterals in the lower esophagus that interconnect portal and systemic circulation in patients with [[portal hypertension]]. Endoscopically, esophageal varices are usually unmistakable and appear as irregular, serpiginous, bluish structures running longitudinally in the submucosa of the esophageal wall. Occasionally, it can be difficult to differentiate small varices from esophageal folds and EUS can be helpful. The presence of varices in patients with cirrhosis is also an independent risk factor for survival.<ref name="pmid6969201">{{cite journal |author=Lebrec D, De Fleury P, Rueff B, Nahum H, Benhamou JP |title=Portal hypertension, size of esophageal varices, and risk of gastrointestinal bleeding in alcoholic cirrhosis |journal=[[Gastroenterology]] |volume=79 |issue=6 |pages=1139–44 |year=1980 |month=December |pmid=6969201 |doi= |url= |accessdate=2012-09-07}}</ref> | ||
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[[Gastroscopy]] (endoscopic examination of the [[esophagus]], stomach and [[duodenum]]) is performed in patients with established cirrhosis to exclude the possibility of [[esophageal varices]]. If these are found, prophylactic local therapy may be applied (sclerotherapy or banding) and [[beta blocker]] treatment may be commenced. | [[Gastroscopy]] (endoscopic examination of the [[esophagus]], stomach and [[duodenum]]) is performed in patients with established cirrhosis to exclude the possibility of [[esophageal varices]]. If these are found, prophylactic local therapy may be applied (sclerotherapy or banding) and [[beta blocker]] treatment may be commenced. | ||
====Endoscopic Ultrasound==== | |||
Endoscopic ultrasound is useful for detecting varices. Varices are seen within the submucosa and in the periesophageal or perigastric soft tissue.<ref name="pmid2184080">{{cite journal |author=Yasuda K, Cho E, Nakajima M, Kawai K |title=Diagnosis of submucosal lesions of the upper gastrointestinal tract by endoscopic ultrasonography |journal=[[Gastrointestinal Endoscopy]] |volume=36 |issue=2 Suppl |pages=S17–20 |year=1990 |pmid=2184080 |doi= |url= |accessdate=2012-09-07}}</ref> In the esophagus, EUS does not appear to be superior to endoscopy in the detection of esophageal varices. On the other hand, EUS is invaluable in differentiating gastric varices from submucosal tumors and prominent gastric folds. In addition, the role of EUS in determining whether or not varices are obliterated is under evaluation. EUS is a very safe procedure with a complication rate of approximately 0.05%. The major complication is perforation, which is related to the relatively large diameter and stiffness of the endoscope used. | Endoscopic ultrasound is useful for detecting varices. Varices are seen within the submucosa and in the periesophageal or perigastric soft tissue.<ref name="pmid2184080">{{cite journal |author=Yasuda K, Cho E, Nakajima M, Kawai K |title=Diagnosis of submucosal lesions of the upper gastrointestinal tract by endoscopic ultrasonography |journal=[[Gastrointestinal Endoscopy]] |volume=36 |issue=2 Suppl |pages=S17–20 |year=1990 |pmid=2184080 |doi= |url= |accessdate=2012-09-07}}</ref> In the esophagus, EUS does not appear to be superior to endoscopy in the detection of esophageal varices. On the other hand, EUS is invaluable in differentiating gastric varices from submucosal tumors and prominent gastric folds. In addition, the role of EUS in determining whether or not varices are obliterated is under evaluation. EUS is a very safe procedure with a complication rate of approximately 0.05%. The major complication is perforation, which is related to the relatively large diameter and stiffness of the endoscope used. | ||
====ERCP==== | |||
If biliary pathology ([[primary sclerosing cholangitis]] - [[PSC]]) is suspected, [[Endoscopic retrograde cholangiopancreatography|ERCP]] may be performed. Generally [[Magnetic resonance cholangiopancreatography|MRCP]] (MRI of biliary tract and pancreas) is sufficient for diagnosis, but ERCP allows for particular interventions, such as placement of a biliary [[stent]] or extraction of [[gallstones]]. | If biliary pathology ([[primary sclerosing cholangitis]] - [[PSC]]) is suspected, [[Endoscopic retrograde cholangiopancreatography|ERCP]] may be performed. Generally [[Magnetic resonance cholangiopancreatography|MRCP]] (MRI of biliary tract and pancreas) is sufficient for diagnosis, but ERCP allows for particular interventions, such as placement of a biliary [[stent]] or extraction of [[gallstones]]. | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2] Vishnu Vardhan Serla M.B.B.S. [3]
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Overview
Tc-99m labeled sulfur can be used in nuclear imaging to obtain an indication of hepatic function. When assessing a patient for a liver transplant, a CTA is used to asses the drainage of the liver.
All patients with cirrhosis should undergo a diagnostic endoscopy for the evaluation of varices. Gastric endoscopy is also an option if gastric varices are suspected, and endoscopic ultrasound can also help in the visualization of varices. ERCP can be done if biliary pathology as a cause of the cirrhosis is suspected.
Other Imaging Findings
Nuclear Imaging
Tc-99m
Tc-99m labeled sulfur used for functional imaging techniques provides some indication of hepatic function. The labeled colloidal compound is taken up by reticuloepithelial cells, and the colloidal shift in other organs (bone marrow,spleen) containing reticuloepithelial cells provides evidence of portal hypertension. [1]
Angiography
Angiography is currently used for assisting in the placement of catheters for CTA. The angiographic findings of hepatic perfusion remains essential in transplant assessment, given the variability of the liver's drainage from its arterial and venous supplies.
Endoscopy
All patients with cirrhosis should undergo a diagnostic endoscopy to document the presence or absence of varices and to determine their risk for variceal hemorrhage. [2] Esophageal varices are dilated collaterals in the lower esophagus that interconnect portal and systemic circulation in patients with portal hypertension. Endoscopically, esophageal varices are usually unmistakable and appear as irregular, serpiginous, bluish structures running longitudinally in the submucosa of the esophageal wall. Occasionally, it can be difficult to differentiate small varices from esophageal folds and EUS can be helpful. The presence of varices in patients with cirrhosis is also an independent risk factor for survival.[3] The appearance of esophageal varices is not diagnostic of the cause of portal hypertension and does not allow for differentiation between portal hypertension secondary to cirrhosis, pre-sinusoidal hypertension, or portal or splenic vein thrombosis. The majority of patients with cirrhosis develop varices and approximately one third bleed at some point.[4] As only one third of patients will bleed, the accurate targeting of those at risk is important. The most popular model used is that devised by the North Italian Endoscopic Club for the Study and Treatment of Oesophageal Varices.[5] The severity of the underlying liver disease, the presence or absence of red markings on the varices, and the size of the varices are the most important risk factors for bleeding.
Gastroscopy (endoscopic examination of the esophagus, stomach and duodenum) is performed in patients with established cirrhosis to exclude the possibility of esophageal varices. If these are found, prophylactic local therapy may be applied (sclerotherapy or banding) and beta blocker treatment may be commenced.
Endoscopic Ultrasound
Endoscopic ultrasound is useful for detecting varices. Varices are seen within the submucosa and in the periesophageal or perigastric soft tissue.[6] In the esophagus, EUS does not appear to be superior to endoscopy in the detection of esophageal varices. On the other hand, EUS is invaluable in differentiating gastric varices from submucosal tumors and prominent gastric folds. In addition, the role of EUS in determining whether or not varices are obliterated is under evaluation. EUS is a very safe procedure with a complication rate of approximately 0.05%. The major complication is perforation, which is related to the relatively large diameter and stiffness of the endoscope used.
ERCP
If biliary pathology (primary sclerosing cholangitis - PSC) is suspected, ERCP may be performed. Generally MRCP (MRI of biliary tract and pancreas) is sufficient for diagnosis, but ERCP allows for particular interventions, such as placement of a biliary stent or extraction of gallstones.
References
- ↑ Kim YS, Cho SW, Lee KJ; et al. (1999). "Tc-99m MIBI SPECT is useful for noninvasively predicting the presence of MDR1 gene-encoded P-glycoprotein in patients with hepatocellular carcinoma". Clin Nucl Med. 24 (11): 874–9. PMID 10551471. Unknown parameter
|month=ignored (help) - ↑ Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W (2007). "Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis". Hepatology (Baltimore, Md.). 46 (3): 922–38. doi:10.1002/hep.21907. PMID 17879356. Retrieved 2012-09-06. Unknown parameter
|month=ignored (help) - ↑ Lebrec D, De Fleury P, Rueff B, Nahum H, Benhamou JP (1980). "Portal hypertension, size of esophageal varices, and risk of gastrointestinal bleeding in alcoholic cirrhosis". Gastroenterology. 79 (6): 1139–44. PMID 6969201. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Christensen E, Fauerholdt L, Schlichting P, Juhl E, Poulsen H, Tygstrup N (1981). "Aspects of the natural history of gastrointestinal bleeding in cirrhosis and the effect of prednisone". Gastroenterology. 81 (5): 944–52. PMID 7026343. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ "Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicenter study". The New England Journal of Medicine. 319 (15): 983–9. 1988. doi:10.1056/NEJM198810133191505. PMID 3262200. Retrieved 2012-09-07. Unknown parameter
|month=ignored (help) - ↑ Yasuda K, Cho E, Nakajima M, Kawai K (1990). "Diagnosis of submucosal lesions of the upper gastrointestinal tract by endoscopic ultrasonography". Gastrointestinal Endoscopy. 36 (2 Suppl): S17–20. PMID 2184080.
|access-date=requires|url=(help)