Hepatic congestion

[Linh]

Dear Steve,

I got a Abdo US referral that ?hepatic congestion. For a normal abdo scan, I would just measure the sizes of the IVC and RT and Mid hepatic veins. Then I state in the report: Referral to Portal Hypertension Vascular US study recommended. Would you have done the same, protocol wise?

What are your limits for these vessels?

In the article I read: Congestive hepatopathy: the role of the radiologist in the diagnosis (2020), they state:
– intrahepatic IVC at rest is 19.4±4.0 mm.
– middle hepatic vein, 6.0±1.5 mm.
– right hepatic vein 5.6–6.2 mm at rest, increasing to 8.8 mm in the presence of heart failure and reaching 13.3 mm in the presence of heart failure with pleural effusion.

Best regards,
Linh

• This topic was modified 3 years, 12 months ago by Linh.

[Stephen Bird]

Hi Linh,

This is a fairly common request and right heart failure / tricuspid regurgitation is a common cause of abnormal LFT’s in older patients.

I don’t get too excited by measurements and numbers in these patients as the diagnosis comes together nicely with subjective criteria.

I think the measurements of the IVC and hepatic veins you quote are perfectly good,

However I think you can simply observe that the IVC is always full and congested throughout the cardiac cycle and the hepatic veins are engorged.
The liver will be enlarged and the inferior edge of the liver will be rounded rather than angular.
The portal vein Doppler will be phasic rather than the usual monophonic pattern.
There is often some pleural effusion(s) and in more severe cases there may be ascites.
The PA chest x-ray will show enlargement of the right heart.

Steve.

[Linh]

Dear Steve,

Thanks for the reply. I sometimes measure the RT hepatic vein just out of interest and find that normal petite patient got large hepatic veins (15mm) but normal IVC (18mm). So I am a bit reluctant to follow these numbers as well. I’ll also look for the subjective signs from now.

Just back to basic: I was taught to measure the liver where the RT kidney in Long is in view with the caliper from supero-posterior to infero-anterior). Some say midclavicular line means measuring the liver in SAG between seeing the RT kidney and the Gallbladder (caliper in horizontal line). How do you measure the liver to keep things consistent and reproducible for follow up?

Best regards,
Linh

[Stephen Bird]

Hi Linh,

There are several methods described and to be honest I think they are all rubbish.

If you measure the length of the right lobe it is super variable with some people having a Riedels lobe, others having a big left liver and short right lobe so I think the natural variation destroys the test. Once again I look more globally. An enlarged liver will have blunt edges, will hang down well over the pancreas and likely cover the right kidney. CT is a much better way to assess liver size as it gives a global perspective.

We take a measurement in the mid clavicular plane and I reckon it is a bit of a waste of time compared to a subjective assessment.

Steve

[Linh]

Yeah, I’m quite confused when measuring the liver when the patient is skinny and they have a Reidel’s lobe. Always MSU with those ones 🙂

[Stephen Bird]

Measuring livers in any single way with ultrasound is going to lead to MSU!

I think taking a global objective assessment approach is better than any single measurement.

We always get snookered with numbers being important in reports, but I can’t help but think the best reports I read have a “specialist medical opinion” rather than a list of numbers.

That is the sort of radiology report I really enjoy reading.

Steve

[Kym Jessup]

Steve,
I found this description of a subjective assessment of liver size super helpful! As a new grad I often find myself looking for definite ‘values’ for normal vs abnormal. I am learning with time to rely more on my overall impression, but pointing out clear, specific descriptors (blunt edges/hanging over pancreas/kidney) to look for is very helpful!
Thanks so much!

Kym

[Stephen Bird]

I like the way you are thinking Kym,

I think good sonographers look at the big picture including multiple points of reference and the clinical presentation before reaching their conclusions.

Nice one,

Steve

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