Risk of Liver Cirrhosis and Hepatocellular Carcinoma after Fontan Operation: A Need for Surveillance

Liver cirrhosis and hepatocellular carcinoma (HCC) are serious late complications that can occur after the Fontan procedure. This study aimed to investigate the cumulative incidence of cirrhosis and HCC and to identify specific features distinguishing HCC from benign arterial-phase hyperenhancing (APHE) nodules that developed after the Fontan operation. We retrospectively enrolled 313 post-Fontan patients who had been followed for more than 5 years and had undergone ultrasound or computed tomography (CT) of the liver between January 2000 and August 2018. Cirrhosis was diagnosed radiologically. The estimated cumulative incidence rates of cirrhosis at 5, 10, 20, and 30 years after the Fontan operation were 1.3%, 9.2%, 56.6%, and 97.9%, respectively. Multiphasic CT revealed that 18 patients had APHE nodules that were ≥1 cm in size and showed washout in the portal venous phase (PVP)/delayed phase, which met current noninvasive HCC diagnosis criteria. Among them, only seven patients (38.9%, 7/18) were diagnosed with HCC. After cirrhosis developed, the annual incidence of HCC was 1.04%. The appearance of washout in the PVP (p = 0.006), long time elapsed since the initial Fontan operation (p = 0.04), large nodule size (p = 0.03), and elevated serum α-fetoprotein (AFP) level (p < 0.001) were significantly associated with HCC. In conclusion, cirrhosis is a frequent late complication after Fontan operation, especially after 10 years, and HCC is not a rare complication after cirrhosis development. Diagnosis of HCC should not be based solely on the current imaging criteria, and washout on PVP and clinical features might be helpful to differentiate HCC nodules from benign APHE nodules.

Imaging and Management of Liver Cancer

Imaging of primary hepatic neoplasms in patients at risk for hepatocellular carcinoma (HCC) and in patients with otherwise normal livers relies on proper multiphase image acquisition technique, with emphasis on a high-quality, late arterial phase, using either CT or MRI for accurate image interpretation. The introduction of liver imaging reporting and data system in 2011, with subsequent multiple updates, the most recent in 2018, has provided standardization of image interpretation, reporting and management recommendations for liver observations in patients at risk for HCC. This review article will emphasize key points of imaging primary liver tumors with emphasis on liver imaging reporting and data system, including strengths of this system. We will also review imaging of less common primary liver tumors such as cholangiocarcinoma and angiosarcomas. Imaging pitfall associated with primary liver malignancies will be demonstrated as well as ways to mitigate them. Finally, imaging and reporting of findings following locoregional treatment of HCC will be reviewed.

Morphometric changes and imaging findings of diffuse liver disease in relation to intrahepatic hemodynamics

Diffuse hepatic diseases have a variety of etiologies, with each showing characteristic morphometric changes. These changes are closely related to micro- and macro-level intrahepatic hemodynamics, in addition to the specific underlying pathophysiology. Short-term disorders in intrahepatic hemodynamics caused by each pathophysiological condition are compensated for by the balance of blood perfusion systems using potential trans-sinusoidal, transversal, and transplexal routes of communication (micro-hemodynamics), while long-term alterations to the intrahepatic hemodynamics result in an increase in total hepatic vascular resistance. Blood flow disorders induced by this increased vascular resistance elicit hepatic cellular necrosis and fibrosis. These changes should be uniformly widespread throughout the whole liver. However, morphometric changes do not occur uniformly, with shrinkage or enlargement not occurring homogeneously. Against this background, several macro-intrahepatic hemodynamic effects arise, such as asymmetrical and complicating morphometric structures of the liver, intricate anatomy of portal venous flow and hepatic venous drainage, and zonal differentiation between central and peripheral zones. These hemodynamic factors and pathophysiological changes are related to characteristic morphometric changes in a complicated manner, based on the combination of selective atrophy and compensatory hypertrophy (atrophy-hypertrophy complex). These changes can be clearly depicted on CT and MR imaging.

Relationship between Heart Disease and Liver Disease: A Two-Way Street

In clinical practice, combined heart and liver dysfunctions coexist in the setting of the main heart and liver diseases because of complex cardiohepatic interactions. It is becoming increasingly crucial to identify these interactions between heart and liver in order to ensure an effective management of patients with heart or liver disease to provide an improvement in overall prognosis and therapy. In this review, we aim to summarize the cross-talk between heart and liver in the setting of the main pathologic conditions affecting these organs. Accordingly, we present the clinical manifestation, biochemical profiles, and histological findings of cardiogenic ischemic hepatitis and congestive hepatopathy due to acute and chronic heart failure, respectively. In addition, we discuss the main features of cardiac dysfunction in the setting of liver cirrhosis, nonalcoholic fatty liver disease, and those following liver transplantation.

Adaptation of the hepatic transudation barrier to sinusoidal hypertension

The role of the hepatic transudation barrier in determining ascites volume and protein content in chronic liver disease is poorly understood. Therefore, the purpose of the present study was to characterize how chronic sinusoidal hypertension impacts hepatic transudation barrier properties and the transudation rate. The suprahepatic inferior vena cava was surgically constricted, and animals were exposed to either short-term (SVH; 2-3 wk) or long-term venous hypertension (LVH; 5-6 wk). Compared with SVH, LVH resulted in lower peritoneal fluid pressure, ascites volume, and ascites protein concentration. The transudation barrier protein reflection coefficient was significantly higher, and the transudation barrier hydraulic conductivity, transudation rate, and transudate-to-lymph protein concentration ratio were significantly lower in LVH animals compared with SVH animals. The sensitivity of transudation rates to acute changes in interstitial fluid pressures was also significantly lower in LVH animals compared with SVH animals. In contrast, there was no detectable difference in hepatic lymph flow rate or sensitivity of lymph flow to acute changes in interstitial fluid pressures between SVH and LVH animals. Taken together, these data suggest that decreased hepatic transudation barrier permeability to fluid and protein and increased reflection coefficient led to a decrease in the hepatic contribution to ascites volume. The present work, to the best of our knowledge, is the first to quantify an anti-ascites adaptation of the hepatic transudation barrier in response to chronic hepatic sinusoidal hypertension.

Liver stiffness measurement in patients with nodular regenerative hyperplasia undergoing magnetic resonance elastography

PURPOSE

Nodular regenerative hyperplasia (NRH) may mimic cirrhosis at imaging. We aim to investigate the effect of NRH on liver stiffness measurement (LSM) obtained with magnetic resonance elastography (MRE).

METHODS

This retrospective, Institutional Review Board-approved study included 37 subjects with NRH (Group 1) and no or minimal fibrosis (F0-F1), a control group (Group 2) made of 30 subjects with non-advanced fibrosis (F0-F2), and a control group (Group 3) made of 30 subjects with advanced fibrosis (F3-F4), all with available MRE. LSM was measured in each subject along with assessment of hepatic morphological features of cirrhosis and signs of portal hypertension. The significance of the difference in mean LSM between Group 1 and 2 and between Group 1 and 3 was evaluated using the Mann-Whitney U test. The difference in distribution of imaging features among groups was assessed using the Pearson χ2 or Fisher exact test.

RESULTS

The mean ± SD LSM in Group 1 (3.56 ± 1.10 kPa) was significantly higher compared to Group 2 (2.91 ± 0.52 kPa, P = 0.019) and significantly lower compared to Group 3 (7.18 ± 2.08 kPa, P < 0.001). Twelve (32%) patients with NRH had LSM ≥ 4.11 kPa, and 6 (16%) patients had LSM ≥ 4.71 kPa. Surface nodularity (P = 0.032) and caudate lobe hypertrophy (P = 0.004) were more commonly visualized in Group 1 than in Group 2. At least one feature of portal hypertension was observed in 16 (43%) NRH subjects.

CONCLUSION

NRH may increase the LSM obtained with MRE and may represent a confounding factor when using liver stiffness for the non-invasive diagnosis of fibrosis.

Imaging of complications following Fontan circulation in children - diagnosis and surveillance

The Fontan operation is performed for various cardiac lesions with single-ventricle physiology. The survival rate of Fontan patients is increasing for adolescents and young adults, with an expected 30-year survival of >80%. Medical health care providers including specialists in organ systems and pediatric radiologists need to improve their knowledge about the Fontan circulation and the various organ complications to monitor care. In this review the author explains the basic anatomical and functional features of Fontan palliation and gives an overview of the multiple long-term organ complications that might present in the pediatric population. These include decreased physical capacity, ventricular dysfunction, atrioventricular valve regurgitation and arrhythmia, as well as protein-losing enteropathy, plastic bronchitis, growth/bone composition disturbances, renal dysfunction, and the recently recognized and important liver fibrosis (Fontan-associated liver disease). Neuropsychological and behavioral deficits occur frequently. This review focuses on the key role of radiology in making the diagnosis of these complications, monitoring therapy and predicting outcomes in the pediatric age group. The author discusses how and when radiology is important in Fontan patients, as well as how new techniques enabling quantitative measures in imaging with US, MRI and CT are adapted for pediatric use, and how they contribute to urgently needed surveillance strategies.

CT and MR imaging findings of the livers in adults with Fontan palliation: an observational study

PURPOSE

To describe liver imaging findings and complications on computed tomography (CT) or magnetic resonance imaging (MRI) in adults with Fontan palliation and investigate whether imaging features show correlations with clinical and physiological parameters.

METHODS

Our Institutional Review Board approved this retrospective study. Two blinded abdominal radiologists reviewed abdominal CT (n = 21) and MRI (n = 16) images between September 2011 and October 2017 in 37 adults (median age 27 years, interquartile range 21-36 years, 14 males [38%]) with a Fontan palliation (median post-Fontan duration 22 years, interquartile range 19-28 years). Correlation between CT/MRI findings and clinical parameters including laboratory results within 6 months of CT/MRI examinations was assessed by Spearman's rank correlation coefficient.

RESULTS

Lobulated hepatic surface and blunt hepatic edge were seen in 92% (34/37) and 95% (35/37) of patients, respectively. Surface nodularity was noted in 32% (12/37). In 7 patients, there were 11 hepatic nodules which showed arterial-phase hyperenhancement and washout. Among them, 2 were biopsy-proven hepatocellular carcinomas (HCCs), and the remaining 9 were focal nodular hyperplasia (FNH)-like nodules. Suprahepatic inferior vena cava (IVC) diameter showed positive correlations with post-Fontan duration (p < 0.01), serum gamma-glutamyl transferase (p < 0.01), and total bilirubin (p < 0.01).

CONCLUSION

The livers in post-Fontan adults show a unique morphology of blunt edge and lobulating surface with occasional nodularity. There is a diagnostic challenge in distinguishing HCCs from FNH-like nodules in post-Fontan population due to overlapping imaging findings. Suprahepatic IVC diameter is a potentially useful imaging marker that reflects hepatic dysfunction in Fontan palliation.

Assessing hepatic impairment in Fontan-associated liver disease using the HepQuant SHUNT test

BACKGROUND & AIMS

Fontan surgery for single ventricle congenital heart disease leads to Fontan-associated liver disease (FALD). Typical laboratory tests, imaging, and histopathology cannot predict clinical severity in FALD. HepQuant SHUNT is a proprietary serum test of hepatic function and physiology that has not yet been evaluated in FALD.

METHODS

Fourteen adult FALD patients at a single urban tertiary care center who underwent a Fontan procedure in childhood received HepQuant SHUNT testing between September 2015 and April 2018. The HepQuant SHUNT disease severity index (DSI) assesses global liver function and physiology from systemic and portal hepatic filtration rates (HFRs, clearances adjusted for body mass) of orally and intravenously administered cholates labeled with deuterium or 13C. The SHUNT parameter of the test measures portal systemic shunting from the ratio of Systemic HFR to Portal HFR. Chart review included laboratory tests, imaging, and clinical findings. Data from FALD patients were compared with data from healthy controls.

RESULTS

The average DSI and SHUNT values for the FALD patients were 17.5% and 36.1%, respectively, compared to 9.2% and 24.1%, respectively, for controls. Twelve (85.7%) FALD patients had a DSI >15 (upper limit of normal). Seven (50.0%) FALD patients had SHUNT values >30% (upper limit of normal), while three FALD patients (21.4%) had SHUNT values >49%. One FALD patient with preoperative SHUNT of 69%, who underwent a combined heart-liver transplant, had confirmed cirrhotic morphology within the liver explant.

CONCLUSIONS

This pilot study demonstrated that most FALD patients had hepatic impairment detected by abnormal DSI, with a smaller number having markedly elevated SHUNT values >49% suggesting intrinsic liver disease. The HepQuant SHUNT test may be useful in detecting and quantifying liver disease severity in FALD patients.

Increased extracellular volume in the liver of pediatric Fontan patients

BACKGROUND

Patients with single ventricle physiology are at increased risk for developing liver fibrosis. Its extent and prevalence in children with bidirectional cavopulmonary connection (BCPC) and Fontan circulation are unclear. Extracellular volume fraction (ECV), derived from cardiovascular magnetic resonance (CMR) and T1 relaxometry, reflect fibrotic remodeling and/or congestion in the liver. The aim of this study was to investigate whether pediatric patients with single ventricle physiology experience increased native T1 and ECV as markers of liver fibrosis/congestion.

METHODS

Hepatic native T1 times and ECV, using a cardiac short axis modified Look-Locker inversion recovery sequence displaying the liver, were measured retrospectively in children with BCPC- and Fontan circulations and compared to pediatric controls.

RESULTS

Hepatic native T1 time were increased in Fontan patients (n = 62, 11.4 ± 4.4 years, T1 762 ± 64 ms) versus BCPC patients (n = 20, 2.8 ± 0.9 years, T1 645 ± 43 ms, p = 0.04). Both cohorts had higher T1 than controls (n = 44, 13.7 ± 2.9 years, T1 604 ± 54 ms, p < 0.001 for both). ECV was 41.4 ± 4.8% in Fontan and 36.4 ± 4.8% in BCPC patients, respectively (p = 0.02). In Fontan patients, T1 values correlated with exposure to cardiopulmonary bypass time (R = 0.3, p = 0.02), systolic and end diastolic volumes (R = 0.3, p = 0.04 for both) and inversely with oxygen saturations and body surface area (R = -0.3, p = 0.04 for both). There were no demonstrable associations of T1 or ECV with central venous pressure or age after Fontan.

CONCLUSION

Fontan and BCPC patients have elevated CMR markers suggestive of hepatic fibrosis and/or congestion, even at a young age. The tissue changes do not appear to be related to central venous pressures.

TRIAL REGISTRATION

Retrospectively registered data.

Liver disease secondary to congenital heart disease in children

Introduction: Hepatic fibrosis and hepatocellular carcinoma (HCC) can develop in children with congenital heart disease. Although hepatic fibrosis and HCC are prone to develop after the Fontan operation, they can also develop in patients suffering from congenital heart disease who have not undergone Fontan operation. Area covered: The history of cardiac hepatopathy including Fontan-associated liver disease is described. Patient characteristics, liver histology, imaging examinations and blood tests are reviewed to elucidate the mechanism of cardiac hepatopathy. In addition, a flowchart for the follow-up management of cardiac hepatopathy in children with congenital heart disease is proposed. Expert opinion: Congestion and low cardiac output are the main causes of cardiac hepatopathy. Advanced hepatic fibrosis is presumed to be associated with HCC. HCC can develop in both adolescents and young adults. Regardless of whether the Fontan operation is performed, children with a functional single ventricle and chronic heart failure should be regularly examined for cardiac hepatopathy. There is no single reliable laboratory parameter to accurately detect cardiac hepatopathy; hepatic fibrosis indices and elastography have shown inconsistent results for detection of this disease. Further studies using liver specimen-confirmed patients and standardization of evaluation protocols are required to clarify the pathogenesis of cardiac hepatopathy.

The modern cardiovascular care unit: the cardiologist managing multiorgan dysfunction

PURPOSE OF REVIEW

Despite many advances in the management of critically ill patients, cardiogenic shock remains a challenge because it is associated with high mortality. Even if there is no universally accepted definition of cardiogenic shock, end-perfusion organ dysfunction is an obligatory and major criterion of its definition.Organ dysfunction is an indicator that cardiogenic shock is already at an advanced stage and is undergoing a rapid self-aggravating evolution. The aim of the review is to highlight the importance to diagnose and to manage the organ dysfunction occurring in the cardiogenic shock patients by providing the best literature published this year.

RECENT FINDINGS

The first step is to diagnose the organ dysfunction and to assess their severity. Echo has an important and increasing place regarding the assessment of end-organ impairment whereas no new biomarker popped up.

SUMMARY

In this review, we aimed to highlight for intensivists and cardiologists managing cardiogenic shock, the recent advances in the care of end-organ dysfunctions associated with cardiogenic shock. The management of organ dysfunction is based on the improvement of the cardiac function by etiologic therapy, inotropes and assist devices but will often necessitate organ supports in hospitals with the right level of equipment and multidisciplinary expertise.

Fitz-Hugh-Curtis syndrome resulting in nutmeg liver on computed tomography

A 34-year-old woman entered the emergency room with abdominal pain in the right upper quadrant. Computed tomography scan showed a nutmeg liver suspected for increased venous pressure by thrombosis of the liver veins, Budd-Chiari malformation, or right-sided heart failure. Interestingly, the diagnosis was pelvic inflammatory disease complicated by the Fitz-Hugh-Curtis syndrome (FHCS).

Pelvic inflammatory disease resulted from an ascended infection by Chlamydia trachomatis. FHCS was caused by perihepatitis defined as inflammation of the peritoneal capsule of the liver. Fast diagnosis and treatment is crucial. Therefore, we report a case of FHCS characterized by a nutmeg liver on computed tomography.

Magnetic Resonance Elastography of Liver in Light Chain Amyloidosis

In this paper, we present our preliminary findings regarding magnetic resonance elastography (MRE) on the livers of 10 patients with systemic amyloidosis. Mean liver stiffness measurements (LSM) and spleen stiffness measurements (SSM) were obtained. Magnetic resonance imaging (MRI) images were analyzed for the distribution pattern of amyloid deposition. Pearson correlation analysis was performed in order to study the correlation between LSM, SSM, liver span, liver volume, spleen span, spleen volume, serum alkaline phosphatase (ALP), N-terminal pro b-type natriuretic peptide (NT pro BNP), and the kappa and lambda free light chains. An increase in mean LSM was seen in all patients. Pearson correlation analysis showed a statistically significant correlation between LSM and liver volume (r = 0.78, p = 0.007) and kappa chain level (r = 0.65, p = 0.04). Interestingly, LSM did not correlate significantly with SSM (r = 0.45, p = 0.18), liver span (r = 0.57, p = 0.08), or serum ALP (r = 0.60, p = 0.07). However, LSM correlated significantly with serum ALP when corrected for liver volume (partial correlation, r = 0.71, p = 0.03) and NT pro BNP levels (partial correlation, r = 0.68, p = 0.04). MRI review revealed that amyloid deposition in the liver can be diffuse, lobar, or focal. MRE is useful for the evaluation of hepatic amyloidosis and shows increased stiffness in hepatic amyloidosis. MRE has the potential to be a non-invasive quantitative imaging marker for hepatic amyloidosis.

Multimodality Imaging of Ileal Neuroendocrine (Carcinoid) Tumor

OBJECTIVE. The purpose of this article is to provide a multimodality imaging review of ileal carcinoid tumor. CONCLUSION. Ileal carcinoid tumors display a variety of radiologic findings. Delay in diagnosis is common because of initial nonspecific symptoms and subtle imaging findings. Reviewing the multimodality imaging appearance of the primary tumor, metastatic disease, and associated ancillary findings can help improve patient care.

Liver fibrosis in biliary atresia

BACKGROUND

Biliary atresia (BA) is the most common cause of obstructive jaundice in infants. Although the Kasai procedure has greatly improved the prognosis, most patients still need liver transplantation (LT) for long-term survival. The pathogenesis of BA has not been fully clarified, and liver fibrosis in BA is far beyond biliary obstructive cirrhosis.

DATA SOURCES

Literature reviews were underwent through PubMed. Persistent inflammation, immune response, biliary epithelial-mesenchymal transition, matrix deposition, decompensated angiogenesis, and unique biliary structure development all contribute to the fibrosis process. Observed evidences in such fields have been collected and form the backbone of this review.

RESULTS

Interactions of the multiple pathways accelerate this process.

CONCLUSIONS

Understanding the mechanisms of the liver fibrosis in BA may pave the way to improved survival after the Kasai procedure.

Heart Failure and Liver Disease: Cardiohepatic Interactions

Heart failure (HF) and liver disease often co-exist. This is because systemic disorders and diseases affect both organs (alcohol abuse, drugs, inflammation, autoimmunity, infections) and because of complex cardiohepatic interactions. The latter, which are the focus of this review, include the development of acute cardiogenic liver injury and congestive hepatopathy in HF as well as cardiac dysfunction and failure in the setting of liver cirrhosis, nonalcoholic fatty liver disease, and sequelae following liver transplantation. The emerging role of altered liver X receptor signaling in the pathogenesis of HF comorbidities as well as of the intestinal microbiome and its metabolites in HF and liver disease are fruitful areas for future research.

Using T1 mapping in cardiovascular magnetic resonance to assess congestive hepatopathy

The goal of this study was to assess the ability of quantitative T1 cardiovascular magnetic resonance (CMR) imaging to calculate liver extracellular volume (ECV) in patients with varying degrees of congestive hepatopathy (CH). T1 measurements and ECV calculations were performed retrospectively in three cohorts of patients: normal cardiac function, tetralogy of fallot (TOF) repair and Fontan palliation. All CMR studies included modified look-locker inversion recovery (MOLLI) T1 mapping scans performed pre- and post-injection of a gadolinium-based contrast agent (GBCA). Pixel intensity data were manually collected from images of the liver and cardiac blood pool to determine contrast-induced changes in T1 for liver and blood. These data were then used to compute liver ECV. 172 subjects were included in the study. Of these, 140 subjects were normal cardiac function patients, 16 were TOF repair patients and 16 patients were with Fontan palliation. A statistically significant difference in both the liver native T1 and ECV measurements was found between patients with normal cardiac function vs. Fontan palliation patients (p < 0.01). Our data indicate that measuring T1 maps both pre- and post-GBCA injection within CMR scan session can be used to follow progression of liver fibrosis. This technique has the potential to improve diagnosis and treatment of patients with chronic liver disease and liver fibrosis.

Magnetic resonance elastography of liver and spleen: Methods and applications

The viscoelastic properties of the liver and spleen can be assessed with magnetic resonance elastography (MRE). Several actuators, MRI acquisition sequences and reconstruction algorithms have been proposed for this purpose. Reproducible results are obtained, especially when the examination is performed in standard conditions with the patient fasting. Accurate staging of liver fibrosis can be obtained by measuring liver stiffness or elasticity with MRE. Moreover, emerging evidence shows that assessing the tissue viscous parameters with MRE is useful for characterizing liver inflammation, non-alcoholic steatohepatitis, hepatic congestion, portal hypertension, and hepatic tumors. Further advances such as multifrequency acquisitions and compression-sensitive MRE may provide novel quantitative markers of hepatic and splenic mechanical properties that may improve the diagnosis of hepatic and splenic diseases.

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

Congestive hepatopathy (CH) arises from chronically elevated right-sided heart pressures transmitted to the liver by passive venous congestion. Over time, CH can lead to hepatic bridging fibrosis, decompensated cirrhosis, and hepatocellular carcinoma. Currently, there are no evidence-based guidelines to direct appropriate screening or management of patients with CH, partly because of the inability of current clinical tools (serum tests, imaging studies, liver stiffness measurements, and liver biopsy) to accurately estimate hepatic fibrosis or the risk for hepatic decompensation. The Model for End-Stage Liver Disease excluding international normalized ratio (MELD-XI) score is the only validated serum-based test to predict clinical outcomes in CH. Noninvasive liver stiffness measurements are proving to be of minimal utility as all patients with CH have elevated values that currently cannot differentiate between congestion and fibrosis. In addition, fibrosis staging by liver biopsy is difficult to standardize because of heterogeneous collagen deposition in CH. Moreover, liver biopsy results have little predictive value for post-heart transplant hepatic outcomes in patients with CH. Evaluating liver nodules and masses is also complicated in CH as the finding of delayed venous washout in nodules is not specific for hepatocellular carcinoma in the background of a congested liver, and these lesions may require biopsy to confirm the diagnosis. The lack of effective clinical tools for predicting liver fibrosis and liver function suggests the need for the development of novel biomarkers in patients with CH to assist in the management of this complicated disease. (Hepatology 2018; 00:000-000).

Hepatic sinusoidal dilatation

Hepatic sinusoidal dilatation refers to the enlargement of the hepatic capillaries. Most of the time this condition is caused by hepatic venous outflow obstruction, which results in vascular stasis and congestion of hepatic parenchyma. In this setting, hepatic sinusoidal dilatation can be related to pericardial disease, heart failure, compression or thrombosis of the hepatic veins or inferior vena cava (i.e., Budd-Chiari syndrome) or central veins/sinusoids involvement (i.e., sinusoidal obstruction syndrome). Nevertheless, some extrahepatic inflammatory conditions (such as pyelonephritis, cholecystitis, pneumonia, pancreatitis, intestinal bowel disease, and others) may be associated with hepatic sinusoidal dilatation without concurrent venous outflow obstruction. On contrast-enhanced cross-sectional imaging, hepatic sinusoidal dilatation is typically characterized by a mottled, reticular enhancement of the liver, usually referred to as "mosaic" pattern. Other hepatic and extrahepatic imaging features, such us the dilatation of the hepatic veins or the presence of ascites, can help in identifying the cause of sinusoidal dilatation.

Congestive hepatopathy

Passive hepatic congestion may result from a variety of distinct cardiovascular conditions. Injury to the liver caused by congestion is often asymptomatic and may not be recognized clinically. Diagnosis of congestive hepatopathy is important as it has the potential to cause complications including hepatic fibrosis and development of benign and malignant liver masses. This review will summarize the pathophysiologic mechanisms of congestive hepatopathy and provide both description and examples of its multimodality imaging findings. Examples of alternative disease which may have a similar imaging appearance will be provided. Knowledge regarding the characteristic imaging findings of congestive hepatopathy will allow for its accurate identification. Reviewing both the benefits and limitations of imaging performed to evaluate congestive hepatopathy and its complications will help to avoid pitfalls and enable recommendation of appropriate next steps in diagnostic evaluation.

Magnetic resonance elastography: beyond liver fibrosis-a case-based pictorial review

Magnetic resonance elastography (MRE) has been introduced for clinical evaluation of liver fibrosis for nearly a decade. MRE has proven to be a robust and accurate technique for diagnosis and staging of liver fibrosis. As clinical experience with MRE grows, the possible role in evaluation of other diffuse and focal disorders of liver is emerging. Stiffness maps provide an opportunity to evaluate mechanical properties within a large volume of liver tissue. This enables appreciation of spatial heterogeneity of stiffness. Stiffness maps may reveal characteristic and differentiating features of chronic liver diseases and focal liver lesions and therefore provide useful information for clinical management. The objective of this pictorial review is to recapture the essentials of MRE technique and illustrate with examples, the utility of stiffness maps in other chronic liver disorders and focal liver lesions.

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

We aimed to illustrate diseases involving the potential space around the hepatic veins. Perivenous halo sign can be seen in patients with congestive heart failure or fluid overload. Perivenous involvement can be observed in patients with alcoholic fatty liver disease, which can be focal or diffuse. Metastasis and primary liver tumor spread can also involve this space most likely due to involvement of lymphatics around hepatic veins.

Nutmeg liver

Nutmeg liver refers to the mottled appearance of the liver as a result of hepatic venous congestion. Radiologically, it is most appreciable on portovenous phase imaging on cross-sectional imaging. It is named after the cut appearance of the nutmeg seed.

Abdominal imaging findings in adult patients with Fontan circulation

Abstract

The Fontan procedures, designed to treat paediatric patients with functional single ventricles, have markedly improved the patient’s survival into adulthood. The physiology of the Fontan circuit inevitably increases systemic venous pressure, which may lead to multi-system organ failure in the long-term follow-up. Fontan-associated liver disease (FALD) can progress to liver cirrhosis with signs of portal hypertension. Focal nodular hyperplasia-like nodules commonly develop in FALD. Imaging surveillance is often performed to monitor the progression of FALD and to detect hepatocellular carcinoma, which infrequently develops in FALD. Other abdominal abnormalities in post-Fontan patients include protein losing enteropathy and pheochromocytoma/paraganglioma. Given that these abdominal abnormalities are critical for patient management, it is important for radiologists to become familiar with the abdominal abnormalities that are common in post-Fontan patients on cross-sectional imaging.

Teaching points

• Fontan procedure for functional single ventricle has improved patient survival into adulthood.

• Radiologists should be familiar with unique imaging findings of Fontan-associated liver disease.

• Focal nodular hyperplasia-like nodules commonly develop in Fontan-associated liver disease.

• Hepatocellular carcinoma, protein-losing enteropathy, pheochromocytoma/paraganglioma may develop.

Electronic supplementary material

The online version of this article (10.1007/s13244-018-0609-2) contains supplementary material, which is available to authorized users.

Cirrhosis and LI-RADS

Chronic liver disease, irrespective of cause, can eventually lead to cirrhosis, which is the primary risk factor for developing hepatocellular carcinoma (HCC). In patients with cirrhosis or appropriate risk factors, HCC can be diagnosed by imaging with high specificity using liver imaging reporting and data system v2017, obviating the need for histologic confirmation. Confident recognition of cirrhosis by conventional imaging alone can be challenging, as radiologists are not always provided with the requisite information to determine if the patient has cirrhosis or other risk factors for HCC. Moreover, cirrhosis-associated abnormalities may impair the diagnostic accuracy of imaging for HCC. This article addresses the diagnosis of cirrhosis by non-invasive imaging and the implications of cirrhosis for imaging interpretation and accuracy.

Benign nodules in post-Fontan livers can show imaging features considered diagnostic for hepatocellular carcinoma

PURPOSE

To describe the imaging appearance of hyperenhancing nodules arising in post-Fontan patients and to identify specific features best correlated with malignancy.

METHODS

Hyperenhancing hepatic nodules visible on CT and/or MRI in post-Fontan patients were identified retrospectively and reviewed by subspecialty radiologists. Nodules with characteristic imaging findings of focal nodular hyperplasia (FNH) were defined as typical, the remainder were defined as atypical, described in detail according to LIRADS criteria, and length of stability over time was recorded. Clinical data, alpha fetoprotein levels (AFP), central venous pressures (CVP), and histopathology were recorded.

RESULTS

245 hyperenhancing nodules (215 typical, 30 atypical) were evaluated in 30 patients. Twenty-nine atypical nodules showed washout (portal phase in 6, delayed phase in 29), 0 showed pseudocapsule, 1 showed threshold growth, 1 showed tumor in vein, and 5 showed ancillary features favoring malignancy. Pathology confirmed hepatocellular carcinoma (HCC) in 3 atypical nodules and FNH-like histology in 3 atypical and 4 typical nodules. 2 atypical nodules were present in a patient with clinical diagnosis of HCC. 20 nodules (7 typical, 13 atypical due to washout) were studied with hepatobiliary contrast agent and all showed homogenous hepatobiliary phase retention. Atypical nodules were significantly more likely to be HCC than biopsy-proven FNH-like or stable ≥24 months when showing portal phase washout (P < 0.001), mosaic architecture (P = 0.020) or in the presence of cirrhosis (P = 0.004) or elevated AFP (P = 0.004). Atypical nodules that were HCC had higher median CVP than those that were FNH-like (19, range 16-27 vs. 13, range 12-16 mmHg, P = 0.0003), there was not a significant difference based on median patient age (HCC 30, range 10-41 vs. FNH-like 40 range 10-41, P = 0.244).

CONCLUSIONS

Benign hyperenhancing masses in Fontan patients may demonstrate washout and be mistaken for HCC by imaging criteria. Portal phase washout, mosaic architecture, elevated AFP and higher CVP were associated with HCC in the atypical nodules found in this population.