Bharmal.pdf

7/26/2019 Bharmal.pdf

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Nazleen Bharmal

Gillian Lieberman, MD

Nazleen

BharmalHarvard Medical School Year III


March 2002

Cirrhosis & Portal Hypertension:

Radiologic Findings


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HPI

50 year-old male presents with confusion

PMH

alcoholism, s/p

cholecystectomy

PE

jaundice, positive abdominal fluid wave

Labs

Abnormal LFTs: nl

aminotransferases,

TBili,

PT,

Alb,

Ammonia,

Alk

Phos

Our Patient

Impression

Alcoholic cirrhosis, Hepatic

encephalopathy


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Menu of Tests

Ultrasound (US)

Computed tomography (CT)

Magnetic resonance imaging (MRI)

Nuclear medicine


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courtesy of BIDMC PACS

Ultrasound of Liver

Ascites

Liver

Our Patient: US Imaging

Doppler studies: patent

portal & hepatic veins


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Differential Diagnosis:Hepatic Ascites*

Sinusoidal Cirrhosis (81%)

SBP

Hepatitis

Liver Metastases

HCC

Post-Sinusoidal Constrictive pericarditis

Right-sided CHF

Tricuspid insufficiency

Budd-Chiari

syndrome

Veno-occlusive disease

Pre-Sinusoidal

Portal or Splenic

vein thrombosis

Schistosomiasis

* Portal Hypertension-Related Etiologies


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Hepatic Anatomy

Sullivan, Lisa. The Liver, Biliary System, and Pancreas. Juhl: Paul and Juhl'sEssentials of Radiologic Imaging, 7th ed., Lippincott Williams & Wilkins, 1998.


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CT Abdomen with IV contrast


CT Abdomen: NormalPatient 1

Aorta

Liver Stomach

Spleen


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Stomach

SpleenAscites

Nodular Liver

Our Patient: CT Imaging

?Falciform

ligament


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Our Patient: Diagnosis

Netter, F.H. The CIBA Collection of Medical Illustrations,Volume 3: Digestive System, Part III, 1957

Liver Cirrhosis

Portal Hypertension

Ascites, Varices,Splenomegaly,

Encephalopathy

LIVER

CIRRHOSIS


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Netter, F.H. The CIBA Collection ofMedical Illustrations, Volume 3:

Digestive System, Part III, 1957

PortalHypertension

Signs &

Symptoms


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Netter, F.H. The CIBA Collection ofMedical Illustrations, Volume 3:

Digestive System, Part III, 1957

PortalSystem:

Portacaval

Anastomoses


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Our Patient

Esophageal Varices


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Esophageal Varices: Another Look

Netter, F.H. The CIBA Collection of Medical Illustrations, Volume 3: Digestive System, Part I, 1957

NormalAnatomy

AbnormalAnatomy


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Esophageal Varices: Barium Study

http://mycourses.me

d.harvard.edu/collec

tion_display.asp?tas

k=framer&tn=y&lo

okupGUID=Head{0

193EB25-8547-

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31E85A142F65}

http://mycourses.med

.harvard.edu/collectio

n_display.asp?task=fr

amer&tn=y&lookup

GUID=Head{33ACA

E5C-C5E8-4D1F-

A23F-

626B72EBF9DC}

Normal Abnormal


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Esophageal Varices: Endoscopy

http://medlib.med.utah.edu/WebPath/GIHT

ML/GI121.hmtl

http://home.t-online.de/home/afreytag/o06e.htm

Normal Abnormal


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CT Abdomen: NormalPatient 1

Aorta

Liver Stomach

Spleen


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Our Patient

Gastric Varices


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Our Patient

More Varices

Spleen & Bowel


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Patient 2

SplenomegalyPatient 3

Ascites

CT Abdomen w/ IV contrast

Anasarca

MR Abdomen T2 Coronal

Ascites


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CT Abdomen without IV contrast


One More FindingOur Male Patient

Gynecomastia Gynecomastia


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Our Patient: Course

High risk for UGIB and HCC

Intractable Ascites

TIPS procedure

Liver Transplant


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TIPS ProcedureOur Patient

TIPS stent with contrast

demonstrates flow fromportal vein to IVC, thus

bypassing the liver

Angiogram


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TIPS Procedure: US Imaging

Liver Ultrasound

Liver

Stent

Our Patient

Ascites


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TIPS Procedure: Color Doppler US

Liver Ultrasound

Our Patient

Patent TIPS

Red = flowtowards transducer

Blue = flow away

from transducer


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The TIPS procedure relieved theascites

somewhat. Our patient

went on to receive a livertransplant.


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References

Netter, F.H. The CIBA Collection of Medical Illustrations, Volume 3: Digestive System, Part

III. CIBA-Geigy, Summit, 1957

Netter, F.H. The CIBA Collection of Medical Illustrations, Volume 3: Digestive System, Part I.

CIBA-Geigy, Summit, 1957

Sabatine, Marc S., MD editor. Pocket Medicine. Lippincott Williams & Wilkins. Philadelphia:

2000. 3-20, 3-22.

Gamuts, Radiology Texts, UptoDateonline

Sullivan, Lisa. The Liver, Biliary System, and Pancreas. Juhl: Paul and Juhl's Essentials of

Radiologic Imaging, 7th ed., Lippincott Williams & Wilkins, 1998, pgs 511-514.

Brown JJ, Naylor MJ, Yagan

N.Imaging of Hepatic Cirrhosis. Radiology 202:1-13, 1997.

Taylor HM, Ros

PR.Hepatic Imaging. Radiologic Clinics of North America 36(2):237-44, March

1998.

Portal Hypertension. The Merch Manual Section 4:Chapter 38, Merck & Co, Inc. New

Jersey:2001


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Acknowledgements

Pamela Lepkowski Gillian Lieberman, MD

Daniel Saurbour, MD Haldon

Bryer, MD

Ravi Thakur, MD Larry Barbaras and Cara Lyn Damour

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Bharmal.pdf