Passive hepatic congestion

Passive hepatic congestion or congested liver in cardiac disease is the stasis of blood in hepatic parenchyma, due to impaired hepatic vein drainage which leads to widening and splaying of central hepatic veins and hepatomegaly

Passive hepatic congestion is a well studied result of acute or chronic right heart failure

Clinical findings on these patients are dominated by those of heart failure. Mild right upper quadrant abdominal pain has been reported to be result of hepatomegally and stretching of hepatic glisson capsule1. Asymptomatic elevation of liver enzymes could also occur 4

Elevated hepatic venous pressure and decrease in hepatic venous flow causes hypoxia in hepatic parenchyma, finally results in diffuse hepatocyte death and diffuse fibrosis. The end of this chain is micronodular cirrhosis, which is not different from cirrhosis produced by other causes 2.

Aetiology

All forms of heart disease (congenital or acquired) are linked to passive hepatic congestion. 

Most common causes of passive hepatic congestion are 4:

Ultrasound

Early in the course of disease the main abnormality is enlargement of right hepatic lobe. Normally right hepatic vein measures less than 6mm and in these patients its mean is about 9mm ref needed

  • real time B-Mode:
    • dilated IVC/hepatic veins, hepatomegaly, ± ascites 
    • diameter of hepatic vein 
      • normal: 5.6 to 6.2 mm
      •  mean diameter: 8.8 mm (in passive congestion) 
      • increases up to 13 mm with pericardial effusion
  • colour Doppler:
    • spectral velocity pattern (lVC & hepatic veins)
      • loss of normal triphasic flow pattern
      • spectral signal may have an "M"shape
      • flattening of Doppler wave form in hepatic veins
      • to-and-fro motion in hepatic veins & IVC
  • spectral velocity pattern (portal vein)
    • increased pulsatility of portal venous Doppler signal
CT
  • early enhancement of dilated IVC and hepatic veins due to contrast reflux from right atrium into IVC
  • heterogeneous, mottled and reticulated mosaic parenchymal pattern with areas of poor enhancement
  • peripheral large patchy areas of poor/delayed enhancement
  • periportal low-attenuation (perivascular lymphedema) 
  • ascites
  • hepatomegaly

On chest images may be seen cardiomegaly and pericardial and pleural effusion4

MRI

Macroscopically CT and MRI are able to depict cirrhotic changes as non-specific findings.

  • T1 (C+ Gd)
    • liver enhancement pattern: reticulated mosaic pattern of low signal intensity linear markings which become more homogenous in 1-2 minutes.
    • hepatic veins & supra hepatic IVC: early enhancement due to reflux from atrium 
    • portal vein: diminished, delayed or absent enhancement
  • fast low-angle shot (FLASH) contrast-enhanced MR image: early reflux of contrast into dilated hepatic veins and IVC
  • T2: periportal high signal intensity (periportal edema
  • MR angiography: slow or absent antegrade flow within IVC

General imaging differential considerations include

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    Article Information

    rID: 22516
    Section: Pathology
    Synonyms or Alternate Spellings:
    • Cardiac related liver disease
    • Cardiac related hepatic disease
    • Passive congestion of the liver

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    Cases and Figures

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    Early enhancement...
    Case 1: contrast reflux from right atrium into IVC
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    Cardiomegaly and ...
    Case 1: cardiomegaly and pleural effusion
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    Case 2
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