Last revised by Mohammad Taghi Niknejad on 4 Jan 2024

Cirrhosis (plural: cirrhoses) is the common endpoint of a wide variety of chronic liver disease processes which cause hepatocellular necrosis. Cirrhosis can be diagnosed with ultrasound, CT, and MRI, and these imaging modalities can also be used to evaluate for possible complications of cirrhosis, such as portal hypertension or hepatocellular carcinoma.

The demographics of cirrhosis reflect the underlying causes. Alcoholism and viral hepatitis from intravenous drug use or in an endemic region are the common causes.

The distribution of underlying etiology will vary regionally, with viral hepatitis being much higher in the developing world, especially in Asia. A typical distribution of causality in Western nations is as follows 4:

The diagnosis is made either at screening for cirrhosis due to known risk factors, elevated liver enzymes, or discovered incidentally in an examination for non-specific symptoms (e.g. right upper quadrant pain). It may also present due to one of its complications:

Focal hepatocellular necrosis caused by a variety of insults (see above) is accompanied by the three characteristics of cirrhosis 3:

  1. fibrosis

  2. nodular regeneration

  3. distortion of hepatic architecture

Although traditionally cirrhosis has been divided into micro-and macronodular cirrhosis, many entities begin as micronodular (<3 mm) 9 and progress to macronodular (e.g. alcoholic cirrhosis), and thus it is of limited utility as a classification scheme 4.

Frequent findings in advanced cirrhosis include hypertrophy of the caudate lobe and lateral segments of the left lobe (segments 2 and 3) with concomitant atrophy of the posterior segments (6 and 7) of the right lobe. These changes are likely related to changes in blood flow between the segments. See article: caudate-right lobe ratio (C/RL).

Imaging is not reliable enough to differentiate between various underlying etiologies.

The main imaging challenge is distinguishing regenerative nodules, siderotic nodules and dysplastic nodules from:

Ultrasound is a major screening tool for cirrhosis and its complications. It is also useful to aid for biopsy. Appearances include:

  • surface nodularity: 88% sensitive, 82-95% specific 5

  • overall coarse and heterogeneous echotexture

  • segmental hypertrophy/atrophy (see above)

    • caudate width: right lobe width >0.65 (43-84% sensitive, 100% specific 5)

    • reduction of the transverse diameter (<30 mm) of the medial segment of the left lobe (segment 4) 11

  • signs of portal hypertension

Sonoelastography may also be useful to assess the amount of liver fibrosis 12. Suggested values for diagnosis are:

  • >7 kPa: advanced fibrosis

  • 12.5-15 kPa: cirrhosis

Contrast-enhanced ultrasound may have a role in the diagnosis of cirrhosis, as diminished mean hepatic venous transit time is similar to that of perfusion CT 13.

CT is insensitive in early cirrhosis. More established findings include:

MRI is also insensitive in early cirrhosis but has a significant role in screening cirrhotic livers for small hepatocellular carcinomas (see LI-RADS). MRI findings include:

  • morphologic changes (same as on CT and ultrasound)

  • regenerative nodules (or cirrhotic nodules)

    • T1

      • variable, usually isointense

      • occasionally mildly hyperintense

      • no early enhancement and washout as most supply is from the portal vein 7,9

    • T2

      • usually isointense 9

      • hypointense if siderotic

  • dysplastic nodules

    • maybe of low or high grade, and thus have a variable appearance

    • low-grade nodules will resemble regenerative nodules

    • high-grade nodules will resemble hepatocellular carcinomas 9

  • small hepatocellular carcinoma (HCC)

    • T1 C+ (Gd)

      • arterial phase enhancement and washout 7

      • late enhancing capsule

      • growth in the interval between studies

    • T2: typically mildly or moderately hyperintense

MR angiography or a balanced steady-state free precession sequence may also be used to assess portal vein patency and portosystemic collaterals.

Treatment depends on the underlying etiology and presence of complications. One of the key roles of diagnostic radiology is the detection of hepatocellular carcinoma (six-monthly ultrasound should be done for surveillance as per 2018 AASLD (American Association for the Study of Liver Diseases) guidelines in cirrhotic patients to screen for hepatocellular carcinoma development) 15. Interventional radiology can be very helpful for the treatment of portal hypertension and its complications (e.g. TIPS, ascites drainage), as well as chemoembolisation or radiofrequency ablation of hepatocellular carcinoma.

The word cirrhosis derives from the Ancient Greek word "κιρρόειν", meaning "to turn reddish-yellow" or "tawny". The French physician René Laennec (1781-1826) was first to use the term to describe the macroscopic appearance of fibrotic changes in a liver with alcoholic cirrhosis.

Several conditions can potentially mimic cirrhosis on imaging 10:

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