Ultrasound Findings in Hepatitis

Nguyễn Thiện Hùng - Phan Thanh Hải - Phạm thị Thu Thủy

Medical Diagnostic Centre (MEDIC)

Hô Chi Minh City - Viêtnam

Presented at Asean Association of Radiology 9 th in Singapore, 1/1997

SUMMARY:

6 criteria such as size, border, posterior surface, parenchyma of liver, portal vein wall and gallbladder proposed by authors to diagnose 817 hepatitis cases (group 1) have the sensibility of 96,81% and the accuracy of 93,39% in comparison with HBV and HCV serological markers. Some changes of liver structure (echo pattern, border, liver angle), portal vein wall and gallbladder have been observed in 1367 cases of viral hepatitis B and C (group 2). The authors also implicate the role and capacity of ultrasound scanning in primary health care for diagnosing of diffuse liver disease to reduce the risks of viral hepatitis and hepatocell carcinoma in Vietnam.

I. INTRODUCTION:

In Vietnam, the role of ultrasound diagnosis in hepatitis is not summed up yet because ultrasound diagnosis has only begun in clinic since 1987 and serological markers of viral hepatitis are only used in the last three years in Hô Chi Minh city. If we apply US well in diagnosing of hepatitis, we may have important premise in primary health care to limit infectious source of viral hepatitis, especially B,C hepatitis, and take down prevalence of hepatocell carcinoma which is high risk in South-East Asia including Vietnam.

This report represents some surveys of hepatitis at Medical Diagnostic Centre in Hô Chi Minh city in two years from 1994.

II. MATERIALS - METHOD:?

There were two groups of patients:

- Group 1: 817 cases were examined by US according to criteria we have proposed (Table 1). Having at least 3 criteria, a patient was tested for HBV, HCV serological markers. When the HBV markers were negative, a second blood test was done after 15 days (5).

TABLE 1: Proposed criteria of diagnosing hepatitis by ultrasound

Proposed criteria	Acute Hepatitis	Chronic Hepatitis
1. Liver Size	Big / Normal	Normal / Small
2. Border	Regular	Irregular / Regular
3. Posterior Surface	Concave	Convex
4. Liver Parenchyma (in comparison with Spleen)	Homogenous -Poor -Rich	Inhomogenous with regenerative nodules Coarse
5. Portal Vein Wall	Hyperechogenic and thickening  5 mm	Hyperechogenic and thickening  5 mm
6. Gallbladder	Edematous thickening or not No bile juice	Deformity, no wall thickening

 - Group 2: 1367 cases, with HBV and HCV serological markers positive, were examined, 403 cases of which with serological markers positive and liver enzymes GOT, GPT, GGT elevated 1,5 times higher than normal (GOT and GPT > 60 UI/L, GGT > 65 UI/L) and 165 other cases with serological markers positive and liver enzymes GOT, GPT, GGT elevated 3 times higher than normal (GOT and GPT > 120 UI/L, GGT > 129 UI/L). Changes of morphology and echo pattern of liver and gallbladder were noted and statistically treated.

We selves examined each patient with KONTRON SIGMA 1, 5.0MHz sector transducer. Liver biopsy cannot be performed in this study.

III. RESULTS:

III.1. Group 1:

Ultrasound Hepatitis (+) = 759 / 817 cases (92.90%),
HBV infection =	679 cases
HCV infection =	27 cases
HBV infection =	23 cases (second test after 15 days)
Other Hepatitis =	30 cases (HBV, HCV negative)
Ultrasound Hepatitis (-) = 58 cases (7.09%), with 24 HBV (+) cases included

 Consequently, suitable evidence between ultrasound diagnosing with HBV, HCV serological markers was represented in following table:

Table 2: Confrontation of results of ultrasound in hepatitis and HBV,  HCV serological markers. 

rHBV-HCV Makers	Positive	Negative
Ultrasound Diagnosis
Positive	729 cases (a)	30 cases (b)
Negative	24 cases (c)	34 cases (d)

a: True positive c: False negative b: False positive d: True negative

- Sensibility = a / a+c = 729 / 729 + 24 = 729 / 753 = 96.81 %

 - Speficity = d / b + d = 34 / 30 + 34 = 34 / 64 = 53.12 %

 - Positive predictive value = a / a+b = 729 / 759 = 96 %

- Negative predictive value = d / c+d = 34 / 58 = 58.6 %

- Accuracy = a+d / sum of cases = 729 + 34 / 817 = 763 / 817 = 93.39%

Fig1: Inferior border and posteriorFig 2: Portal vein wall hyperechoic and

surface of chronic hepatitis thickening in hepatitis.

III.2. Group 2:

Some morphologic changes of liver and gallbladder in1367 cases hepatitis B and C but nonspecific were observed by ultrasound diagnosis ( Table 3).

 

Ultrasound Characters	Hepatitis (US+ Markers+) N = 1367 cases		Hepatitis (US+, Markers+, Liver Enzymes increased 1.5 times more than normal: GOT and GPT  60UI/L ; GGT 65UI/L) N = 403 cases		Hepatitis (US+, Markers+, Liver Enzymes increased 3 times more than normal GOT and GPT120UI/L; GGT  129UI/L)   N = 165 cases
	Number	%	Number	%	Number	%
Pattern Coarse	211	15.4%	70	17.4%	28	17%
Rich	196	14.3%	73	18.1%	37	22.4%
Poor	149	10.9%	43	10.7%	20	12.1%
Regenerative nodules	132	9.7%	51	12.7%	22	13.3%
Homogenous	489	56.5%	209	51.9%	80	48.4%
Hepatomegaly	330	24.1%	108	26.8%	151	30.1%
Portal vein wall thickening	96	7%	32	7.9%	23	13.9%
Posterior Surface Convex	276	20.2%	86	21.3%	32	19.4%
Border Irregular	56	3.7%	29	7.2%	14	8.5%
Bumpy	5	0.4%	2	0.5%	1	0.6%
Regular	1032	75.5%	296	73.4%	124	75.2%
Obtuse Liver Angle	18	1.3%	9	2.2%	7	4.2%
Gallbladder Small	4	0.29%	3	0.74%	3	1.8%
Not noted	964	70.51%	265	65.75%	102	61.81%
No bile juice	4	0.29%	3	0.74%	3	1.81%
Deformed	45	3.29%	24	5.95%	8	4.84%
Edematous thickening wall	12	0.87%	9	2.23%	4	2.42%
Not observed	2	0,14%
Normal	331	24.21%	96	23.82%	43	26.06%

IV. DISCUSSION:

Changes of echogenic structure in acute hepatitis, chronic hepatitis and cirrhosis were implicated but not systematized adequately yet. As for size, liver is usually big in acute hepatitis, and normal in chronic stage (2,3,4). Our data show hepatomegaly from 24.1% to 30.1%. In acute hepatitis (H2), liver has hypoechogenic structure (dark liver) and that may be met in leukemia, toxic shock syndrome, liver congestion, AIDS, post radiation and normal status (3). Hypoechogenic structure of liver in our data are from 10.7% to 12.1%. There was an idea that severe acute liver inflammation decreases echogenecity (4). In acute alcoholic hepatitis, liver is usually big and hyperechogenic (bright liver) with attenuation as in fatty infiltrating liver (3) (H3). We realize that there are neither attenuation nor decreasing of vascular structure. Rich echogenecity of liver in hepatitis of our data is from 14.3% to 22.4%. In acute hepatitis, hyperechodense of portal vein wall (3,4) in a dark liver was called as centrilobular pattern, and we met it either in acute and chronic hepatitis with a thickness more than 5 mm at the main portal vein. Our data show that thickening and hyperechodense of portal vein wall is from 7.0% to 13.9%.

Active chronic hepatitis usually changed liver structure more than persistent chronic hepatitis (4) with coarsening liver parenchyma, and hypoechogenic portal triad but no attenuation like fatty infiltrating liver (H1). Our data show coarse pattern of liver from 15.4% to 17.0%. In cases of severe hepatic dysfunction, the surface of liver becomes irregular. This finding reflects the formation of regenerative nodules associated with blunted inferior edge and convex posterior surface (2). In our data, nodular regeneration is from 9.7% to 13.3% and convexity of posterior surface is from 19.4% to 21.3%.

Gallbladder wall is usually edematous thickening in acute hepatitis (4) and cirrhosis (2). In our data, this edematous thickening is from 0.87% to 2.42% (H2). Deformity of the gallbladder is frequently secondary to deformity of the liver (2), we noted it from 3.29% to 5.95% of cases.

In addition, changes of liver structure in hepatitis are polymorphous but nonspecific and in a few proportion. We think that may be the cause of difficulty of ultrasound diagnosing in hepatitis though many workers agree that ultrasound is a sensitive technique for distinguishing normal from abnormal liver (3).

 V. CONCLUSION:

 Ultrasound is a noninvasive diagnostic imaging technique with high sensitivity in liver disease. The accuracy of ultrasound diagnosing in hepatitis of our study is 93.39%. According to our results, we realize that the systemization of our proposed diagnosing criteria is simplified and helpful for orientation of diagnosis in routine examination.

Acknowledgments:

We would like to acknowledge the physicians of Liver Disease Department (MEDIC2), Phi Tuân Hung, MD and Pham Công Chanh, MD who contributed to gather clinical data for this study.

References:

1. DAFFIRI,R. et al: Apport de léchographie dans la tuberculose des viscères pleines de labdomen. J.Radio., N^o 2, 1990.

2. HIGASHI, T. et al: Introduction to Abdominal Ultrasonography, Springer-Verlag Berlin Heidelberg, 1991.

3. IRVING, H.C.: Diffuse Liver Disease, pp. 295-307, Clinical Ultrasound, Vol.1, Churchill Livingstone, 1st ed., 1994.

4. HAGEN-ANSERT, SL: The Liver, pp.99-158, Textbook of Diagnostic Ultrasonography (Volume 1), 4^th ed. Mosby-Year Book, 1995.

5. NGUYỄN THIỆN HÙNG et al: Ultrasound in B and C Hepatitis, MEDIC 1994.

6. NGUYỄN THIỆN HÙNG et al: Changements of Liver Structure Ultrasound in B and C Hepatitis, MEDIC 1996.