Imaging Findings of Congestive Hepatopathy

Abstract

Congestive hepatopathy (CH) refers to hepatic abnormalities that result from passive hepatic venous congestion. Prolonged exposure to elevated hepatic venous pressure may lead to liver fibrosis and cirrhosis. Liver dysfunction and corresponding clinical signs and symptoms typically manifest late in the disease process. Recognition of CH at imaging is critical because advanced liver fibrosis may develop before the condition is suspected clinically. Characteristic findings of CH on conventional images include dilatation of the inferior vena cava and hepatic veins; retrograde hepatic venous opacification during the early bolus phase of intravenous contrast material injection; and a predominantly peripheral heterogeneous pattern of hepatic enhancement due to stagnant blood flow. Extensive fibrosis can be seen in chronic or severe cases. Hyperenhancing regenerative nodules that may retain hepatobiliary contrast agents are often present. Magnetic resonance (MR) elastography can show elevated liver stiffness and may be useful in evaluation of fibrosis in CH because it can be incorporated easily into routine cardiac MR imaging. Preliminary experience with MR elastography suggests its future use in initial evaluation of patients suspected of having CH, for monitoring of disease, and for assessment after therapy. To facilitate appropriate workup and treatment, radiologists should be familiar with findings suggestive of CH at radiography, ultrasonography, computed tomography, MR imaging, and MR elastography. In addition, knowledge of underlying pathophysiology, comparative histologic abnormalities, and extrahepatic manifestations is useful to avoid diagnostic pitfalls and suggest appropriate additional diagnostic testing. (©)RSNA, 2016.

Assessment of Advanced Liver Fibrosis and the Risk for Hepatic Decompensation in Patients With Congestive Hepatopathy

“…Given the underlying pathophysiology of CH and limited correlation of individual serum markers with fibrosis stage, clinical risk calculators are unlikely to effectively predict fibrosis risk in CH . For example, several models heavily weight aminotransferase values as markers of liver necroinflammation, but CH is not an inflammatory disease . Among 27 patients with FALD, the positive predictive value (PPV) and negative predictive value (NPV) of FibroSure for identifying evolving or established cirrhosis when compared to liver biopsy were 33.3% (PPV) and 52.6% (NPV).…”

“…Vasoconstriction results in zone 3 sinusoidal ischemia and fibrosis deposition, leading to bridging fibrosis, cirrhosis, and even hepatocellular carcinoma (HCC). In addition, low cardiac output itself may also lead to low circulating blood flow to the liver, accelerating fibrosis pathways …”

Imaging of pathology involving the space around the hepatic veins: "perivenous pattern"

“…Increased hydrostatic pressure within the IVC and hepatic vein lumens subsequently gives rise to sluggish flow within the intrahepatic venous outflow network, which eventually may lead to nutmeg liver appearance and hepatocyte necrosis (10).…”

Congestive hepatopathy: Differentiating congestion from fibrosis

“…Congestive hepatopathy arises from chronically elevated hepatic venous pressures secondary to right‐sided heart failure. Elevated cardiac pressures are transmitted to the central veins of the liver and over time cause presinusoidal dilation, decreased hepatic artery blood flow, and decreased arterial oxygen saturation that leads to bridging fibrosis, cirrhosis, and even hepatocellular carcinoma (HCC) . An ideal and frequently studied model for congestive liver disease is Fontan‐associated liver disease, where patients have liver congestion for decades after receiving a cardiac Fontan operation for single ventricle congenital heart defects (Fig.…”

“…Characteristic findings of congestive hepatopathy on imaging include hepatomegaly, dilated venous structures, nodular appearance of the liver, and frequently hyperenhancing nodules. Ultrasound usually demonstrates hepatomegaly and dilation of the inferior vena cava and hepatic veins caused by congestion with increased portal pressure measurements . Computed tomography (CT) and magnetic resonance imaging (MRI) typically show hepatomegaly and a nodular appearance of the liver with a fairly high prevalence rate (approximately 30%) of hyperenhancing hepatic nodules that may mimic focal nodular hyperplasia (FNH), but can also be difficult at times to discern from HCC .…”