Use of Ultrasound in NAFLD
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1 Institute for Liver and Digestive Health Use of Ultrasound in NAFLD Dr. Davide Roccarina Specialist in General Medicine Specialist Doctor in Clinical Ultrasound and non-invasive liver assessment Hepatology Department Division of Medicine Royal Free Hospital
2 Diabetes type 2 Insulin resistance Cardiovascular disease Hypertension Fatty Liver disease (NAFLD/NASH)
3 The Hepatology Menu HEREDITARY HCV NAFLD ALCOHOL AUTOIMMUNE HBV
4 The Hepatology Menu HEREDITARY NAFLD ALCOHOL HCV AUTOIMMUNE HBV
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6 LIVER STEATOSIS Accumulation of fat within the liver as a non-specific response to a wide variety of etiologies.
7 NAFLD Non-Alcoholic Fatty Liver Diseases Decompensation HCC Jonathan C. Cohen, Science 2011
8 Jonathan C. Cohen, Science 2011 NAFLD Non-Alcoholic Fatty Liver Diseases Decompensation HCC
9 LIVER STEATOSIS The diagnosis can be made histologically when more than 5% of hepatocytes contain fat as lipid vacuoles in the cytoplasm. When the fat accumulated into the liver affects over 20-25% of hepatocites it can be sonographically detected as an increased echogenicity of liver parenchyma.
10 Clinical US in Liver Steatosis In liver steatosis three different features can influence its sonographic appearance: 1. The size of the liver 2. The amount of fat in the liver 3. The distribution of fat in the liver
11 Clinical US in Liver Steatosis In liver steatosis three different features can influence its sonographic appearance: 1. The size of the liver 2. The amount of fat in the liver 3. The distribution of fat in the liver
12 Clinical US in Liver Steatosis Longitudinal Right lobe = 17 cm (n.v. 15 cm) Usually the right lobe of the liver is enlarged and the liver margins are rounded
13 Clinical US in Liver Steatosis In liver steatosis three different features can influence its sonographic appearance: 1. The size of the liver 2. The amount of fat in the liver 3. The distribution of fat in the liver
14 Clinical US in Liver Steatosis Amount of fat 3 grades of liver steatosis can be sonographically described according to the appearance of liver echogenicity, liverkidney contrast, gallbladder wall, vessels and diaphragm Grade 1 or mild steatosis Grade 2 or moderate steatosis Grade 3 or severe steatosis Ultrasound beam reflection Ultrasound beam attenuation Ultrasound beam attenuation
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16 Clinical US in Liver Steatosis Grade 1 or mild steatosis Diffuse increase in the echogenicity of liver tissue (bright liver) compared to the echogenicity of the right renal cortex (liverkidney contrast). Normal visualization of diaphragm, gallbladder wall, hepatic veins contour and lumen, portal branches walls
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20 Clinical US in Liver Steatosis Grade 2 or moderate steatosis Further increased brightness with reduced visualization of hepatic veins contour and lumen, portal branches walls, gallbladder wall. Diaphragm remains still well defined.
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24 Clinical US in Liver Steatosis Grade 3 or severe steatosis The attenuation of ultrasound beam does not allow to visualise the diaphram profile.
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29 Clinical US in Liver Steatosis Grade 3 or severe steatosis In this case the deep liver segments cannot be appropriately assessed and focal liver lesions can potentially be missed.
30 Clinical US in Liver Steatosis Grade 3 or severe steatosis In case of HCC surveillance an enhanced second-level imaging (CT or MRI) are strongly advised
31 Clinical US in Liver Steatosis In liver steatosis three different features can influence its sonographic appearance: 1. The size of the liver 2. The amount of fat in the liver 3. The distribution of fat in the liver
32 Clinical US in Liver Steatosis Distribution of fat Geographic Fatty Liver Focal fatty sparing area Focal fatty infiltration area
33 Clinical US in Liver Steatosis Distribution of fat Geographic Fatty Liver Focal fatty sparing area Focal fatty infiltration area
34 The fat has an irregular distribution within the liver with large areas giving to the liver a geographic appearance
35 Clinical US in Liver Steatosis Distribution of fat Geographic Fatty Liver Focal fatty sparing area Focal fatty infiltration area They may mimic focal liver lesions (haemangioma, FNH, adenoma, HCC, metastasis).
36 Clinical US in Liver Steatosis Distribution of fat Geographic Fatty Liver Focal fatty sparing area Focal fatty infiltration area
37 Clinical US in Liver Steatosis Distribution of fat Typical distribution: around the gallbladder porta hepatis and portal biforcation below the liver capsule adjacent to the falciform ligament Typical sonographic features: small hypoechoic areas irregular contour Differential diagnosis with tumours sharp angulated boundaries and interdigitation with the normal tissue absence of mass effect (no vessel displacement-distortion-encasement, no bulging effect of gallbladder and liver capsule)
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41 Clinical US in Liver Steatosis Distribution of fat Geographic Fatty Liver Focal fatty sparing area Focal fatty infiltration area
42 Clinical US in Liver Steatosis No typical distribution: Distribution of fat Typical sonographic features: small hyperechoic areas irregular contour Differential diagnosis with tumours sharp angulated boundaries and interdigitation with the normal tissue absence of mass effect (no vessel displacement-distortion-encasement, no bulging effect of gallbladder and liver capsule)
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49 Clinical US in Liver Steatosis Distribution of fat Fatty infiltration Fatty sparing An enhanced second-level imaging (CEUS, CT or MRI) is strongly recommended
50 Clinical US in Liver Steatosis The hepatic steatosis may change the expected appearance of a sonographic finding. For example a hepatic haemangioma which is typically hyperechoic may become hypoechoic on the background of hepatic steatosis.
51 TAKE HOME MESSAGES Ultrasound is useful for assessing and staging liver steatosis, and identifying different patterns of fat distribution Severe steatosis with high posterior attenuation can potentially cover an underlying focal lesion. Focal fatty sparing/infiltration aereas may mimic a focal liver lesion (haemangioma, adenoma, HCC) and sometimes the differential diagnosis may be difficult. In this case an enhanced second level imaging is strongly advised
52 THANK YOU
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