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Review
. 2015 May 26:2:90-100.
doi: 10.1016/j.ejro.2015.05.002. eCollection 2015.

State-of-the-art imaging of liver fibrosis and cirrhosis: A comprehensive review of current applications and future perspectives

Adrian Huber  1 , Lukas Ebner  1 , Johannes T Heverhagen  1 , Andreas Christe  1
Affiliations
Review

State-of-the-art imaging of liver fibrosis and cirrhosis: A comprehensive review of current applications and future perspectives

Adrian Huber et al. Eur J Radiol Open. .

Abstract

Objective: The purpose of this article is to provide a comprehensive overview of imaging findings in patients with hepatic fibrosis and cirrhosis; and to describe which radiological/clinical modality is best for staging hepatic fibrosis.

Conclusion: MR elastography (MRE) appears to be the most reliable method for grading liver fibrosis, although the CT fibrosis score derived from the combination of caudate-to-right-lobe ratio and the diameters of the liver veins significantly correlates with the stage of fibrosis.

Keywords: CT fibrosis score; Fibroscan; Hepatic fibrosis; Liver cirrhosis; Magnetic resonance elastography (MRE).

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Figures

Fig. 1
Fig. 1
(A) Liver cirrhosis in ultrasonography: inhomogeneous liver parenchyma (asterisk) with surface nodularity (arrow). (B) Portal venous hypertension with dilation of portal vein, splenomegaly (C) and collateral vessels within the abdominal wall (D).
Fig. 2
Fig. 2
Ultrasonography of a 25-year-old patient suffering from haemochromatosis. (A) Inhomogenous liver parenchyma with surface nodularity (white arrow). (B) Caudate lobe is enlarged (asterisk, sagittal plane). (C) Splenomegaly 17 cm. (D) Hepatofugal flow in the left portal vein (stream inversion).
Fig. 3
Fig. 3
Ultrasonography of a 64-year-old male patient suffering from Laennec's cirrhosis. (A) Regular hepatopetal blood flow in the right portal vein. (B) Remodelling of the liver with compression of the middle hepatic vein (6 mm diameter), note the HCC in the periphery of the liver (white arrow).
Fig. 4
Fig. 4
Ultrasonography of a 64-year-old female patient suffering from hepatitis C induced cirrhosis. (A) Hyperechoic fatty liver. (B) Massive collateral vessels (umbilical vein, white arrow), dilated main portal vein (black arrow, 19 mm). (C) Gastrolienal collateral veins and splenomegaly. (D) Dilated umbilical vein. (E) Subhepatic collateral veins.
Fig. 5
Fig. 5
(A, B) CT of liver cirrhosis with right lobe atrophy and left lobe hypertrophy complex with a caudate (arrow) to right (asterisk) lobe ratio >1. (C) Right vein diameter <7 mm due to compression of cirrhotic liver parenchyma; note additional gynecomasty (asterisk). (D) Signs of portal venous hypertension with recanalisation of umbilical vein and therefore no extensive splenomegaly (asterisk).
Fig. 6
Fig. 6
Pathologic caudate–right-lobe ratio (CRL) in a patient with pre-cirrhotic liver fibrosis (CT): hypertrophy of the left and atrophy of the right liver. In axial planes a line parallel to the midsagittal plane was drawn through the right lateral wall of the first bifurcation of the right portal vein. Distances perpendicular to the drawn line to the most medial margin of the caudate lobe and the lateral margin of the right lobe midway between the main portal vein and the inferior caval vein were measured. The two distances were divided (caudate lobe/right lobe) and defined as the caudate–right-lobe ratio (CRL). The sum of liver vein diameters (LD) equals 7.8 mm. LD divided by CRL equals the CT fibrosis score, which is below 20 and therefore compatible with liver cirrhosis.
Fig. 7
Fig. 7
CT of a 58-year-old female patient with alcoholic liver cirrhosis. Large collateral vessels (black arrows): re-opened umbilical vein (A), gastro-lienal collaterals (B). Because of the re-opening of the umbilical vein the spleen (asterisk) usually does not enlarge. Note the nodularity of the liver surface (white arrow).
Fig. 8
Fig. 8
CT of a 57-year-old female patient, suffering from alcoholic liver cirrhosis. (A) Native phase without contrast. (B) Late arterial phase. (C) Portal venous phase. (D) Equilibrium phase. Atrophic liver with ascites is evident. Early nodular enhancement is depictable in the arterial phase (white arrow, B), there is no wash-out of this liver nodule, compatible with a regenerative or dysplastic nodule, HCC is less probable. Other regenerative nodules with the same enhancement pattern are shown (black arrow). Ascites on all slices is evident (asterisk).
Fig. 9
Fig. 9
Liver cirrhosis in MRI. (A) T2 haste sequence: nodular liver surface (white arrow) with hypertrophic caudate lobe (asterisk) and splenomegaly (black arrow). (B) T1 vibe fat saturated post-gadolinium image displays the inhomogeneous liver parenchyma with many hypovascular regenerative nodules (white arrow) and ascites (black arrow). (C) Diffusion weighted image b800 showed slight inhomogeneous intensity of the liver. (D) Ep2d diffusion ADC-maps displays hypointense liver signal (asterisk) compared to a normal liver MRI. (E) Diffusion weighted image b800 of a normal liver with homogeneous liver signal. (F) Ep2d diffusion ADC-maps of normal liver with brighter signal than the cirrhotic liver (D).
Fig. 10
Fig. 10
MRI of a 61-year-old male patient with hepatitis B induced liver cirrhosis and HCC. (A) T1 weighted fat saturated native phase without contrast. (B) Late arterial phase. (C) Portal venous phase. (D) Equilibrium phase. Early HCC enhancement is demonstrated in the arterial phase (white arrow, B), there is wash-out of the contrast media in the later phases (C, D). Surface nodularity (black arrow) and hypertrophy of the caudate lobe (asterisk) with atrophy of the right liver is evident.
Fig. 11
Fig. 11
MRI of a 48-year-old female patient suffering from hepatitis B and C. Coronal T2 haste fat saturated images at the level of the gall bladder (A) and the kidneys (B). Small atrophic right liver with a cranio-caudal distance of 10 cm and prominent left liver (asterisk) with splenomegaly (17.5 cm).
Fig. 12
Fig. 12
Pathologic caudate–right-lobe ratio (CRL) in a patient with hepatitis B induced liver cirrhosis (MRI, T2 weighted haste): hypertrophy of the left and atrophy of the right liver. A dashed line parallel to the midsagittal plane was drawn through the right lateral wall of the first bifurcation of the right portal vein. The two distances of the caudate lobe (C) and right lobe (R) were divided and defined as the caudate–right-lobe ratio (CRL). The sum of the three liver vein diameters (LD) equals 12.1 mm. LD divided by CRL equals the CT fibrosis score, which is below 20 and therefore compatible with liver cirrhosis.
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