Passive hepatic congestion

Dr Dan J Bell and Dr Bruno Di Muzio et al.

Passive hepatic congestion or congested liver in cardiac disease is the stasis of blood in the hepatic parenchyma, due to impaired hepatic venous drainage which leads to widening and splaying of the 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 right heart failure. Mild right upper quadrant abdominal pain has been reported to be the result of hepatomegaly and stretching of the hepatic Glisson capsule 1. Asymptomatic elevation of serum liver enzymes may also occur 4

Elevated hepatic venous pressure and decrease in hepatic venous flow causes hypoxia in hepatic parenchyma, finally resulting in diffuse hepatocyte death and fibrosis. The end of this chain is micronodular cirrhosis, which is indistinguishable from cirrhosis produced by other causes 2.

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

Most common causes of passive hepatic congestion 4:

Early in the course of disease the main abnormality is enlargement of the right hepatic lobe. Normally the right hepatic vein measures <6 mm and in these patients its mean is ~9 mm 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 waveform in hepatic veins
      • to-and-fro motion in hepatic veins and IVC
  • spectral velocity pattern (portal vein)
    • increased pulsatility of portal venous Doppler signal
  • 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 lymphoedema) 
  • ascites
  • hepatomegaly

Chest images may show cardiomegaly and pericardial and pleural effusion 4

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 & suprahepatic IVC: early enhancement due to reflux from the atrium 
    • portal vein: diminished, delayed or absent enhancement
  • fast low-angle shot (FLASH) contrast-enhanced MRI: early reflux of contrast into dilated hepatic veins and IVC
  • T2: periportal high signal intensity (periportal oedema
  • 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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