Diffuse Liver Disease:
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1 Diffuse Liver Disease: MRI Evaluation Fat Iron Cirrhosis Donald G. Mitchell, M.D. Thomas Jefferson University Philadelphia, PA
2 Fatty Liver Disease Common, increasing» Diabetes» Diet, high fructose corn syrup, etc» Metabolic syndrome NASH (vs. benign NAFLD)» Inflammation, fibrosis» Primary cause of cryptogenic cirrhosis Goals:» Measure fat and response to intervention» Detect inflammation and early fibrosis»? Other disease parameters (e.g. mesenteric adiposity)
3 Dual Echo GRE (2D) In-phase & Opposed-Phase with exact same anatomy TE = 4.6 msec TE = 2.3 msec
4 Lifestyle Change 6 mos F/U
5 Nodular Fatty Infiltration
6
7 Fatty Liver Disease: Methods Dual GRE (2-point Dixon)» Included in routine protocols» Confounded by iron» Ambiguity near 50% lipid signal 3-point Dixon» Longer acquisition» Resolves iron and other T2 differences» Algorithm should account for multiple lipid peaks Spectroscopy» Resolves 50% lipid ambiguity
8 3-Point Dixon
9
10 Fatty Liver Disease: 3T Dixon Techniques» Shorter TE intervals Spectroscopy» Greater lipid-water separation TE = 1.15 Experience, Literature TE = 2.3
11 Hemochromatosis» Primary (genetic) Phlebotomy» Erythrogenic (e.g. Thalasemia) Ineffective erythropoiesis May be exacerbated by transfusions» Exogenous Transfusional Siderosis» Reticuloendothelial» Usually not clinically significant Hemolysis» Intravascular (free hemoglobin)» Extravascular (splenic) Cirrhosis» Mildly increased iron is common
12 Iron Overload: Methods Dual GRE (2-point Dixon)» Included in routine protocols» Confounded by lipid» Moderately sensitive Multi-echo GRE» Longer acquisition» Resolves lipid and other CS differences» Affected by microscopic distribution of iron» Too sensitive (can t t measure severe overload) Multi-echo SE» Even longer acquisition?calibration between SI to iron concentration
13 TE = 0.9 TE = 1.7 TE = 2.6 TE = 3.5 TE = 4.3 TE = 5.2
14 Multi-Echo TE = 4.6
15 Transfusional Siderosis
16 Hemochromatosis
17 Idiopathic Hemochromatosis Fatty Liver - Iron Overload - Cirrhosis
18 Intravascular Hemolysis Paroxysmal Nocturnal Hemoglobinuria Sickle Cell Anemia
19 Hepatitis C, NASH, etc Early Fibrosis» Morphology» Diffusion» Elastography» Spectroscopy» Perfusion» Etc. Complications» HCC» Portal Hypertension» Esophageal Varices
20 Morphologic Signs Nodular Contour & Texture Peripheral Right & Medial Atrophy / Caudate & Central Hypertrophy» Empty GB Fossa» Wide Porta Hepatis and Falciform Ligament» Anterolateral Flattening» Caudate/Right Lobe > 1
21 Caudate / Right Lobe Ratio RPV MPV Harbin WP, Robert NJ, FerrucciJT. Radiology 1980; 135: X A C/R > 0.65 X A C/R > Awaya H, Mitchell DG, et al. Radiology 2002; 224:
22 Cirrhosis Expanded GB Fossa Normal 68% sensitive, 98% specific, 98% PPV for cirrhosis. Ito K, Mitchell DG, Gabata T, Hussain SM. Radiology 1999; 211: Early Cirrhosis
23 Normal Hilar Periportal Space 98% of early cirrhosis (no nodularity) vs. 11% of control (p<.0001); 91% positive predictive value. Ito K, Mitchell DG, Gabata T. JMRI 2000; 11: Early Cirrhosis
24 Conclusions 1. MRI is highly effective for imaging fatty liver, iron overload, and cirrhosis and its complications. 2. Important goals are measurement of iron concentration, and detection of early fibrosis.
25
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