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Ultrasound Findings in Hepatitis

Hung Thien Nguyen – Hai Thanh Phan - Thuy Thu thi Pham
Medic Medical Centre (MEDIC)
Hoâ Chi Minh City - Vieâtnam

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 1,367 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 Hoâ
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 Hoâ 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
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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 Homogenous Inhomogenous with

(in comparison with regenerative nodules
-Poor
Spleen) Coarse
-Rich

5. Portal Vein Wall Hyperechogenic and Hyperechogenic and

thickening ≥ 5 mm thickening ≥ 5 mm

6. Gallbladder Edematous Deformity, no wall

thickening or not thickening
No bile juice

- 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 andø
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,

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HCV serological markers was represented in following table:

Table 2: Confrontation of results of ultrasound in hepatitis and HBV,

HCV serological markers.

HBV-HCV markers 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%

Fig.A: Inferior border and posterior Fig.B : 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
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hepatitis B and C but nonspecific were observed by ultrasound diagnosis ( Table 3).

Ultrasound Hepatitis (US+ Hepatitis (US+, Markers+, Hepatitis (US+, Markers+,

Characters Markers+) Liver Enzymes increased 1.5 Liver Enzymes increased 3
times more than normal: times more than normal
N = 1367 cases
GOT and GPT ≥ 60UI/L ; GOT and GPT≥120UI/L;

GGT ≥ 65UI/L) GGT ≥ 129UI/L)

N = 403 cases 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 132 9.7% 51 12.7% 22 13.3%

nodules

Homogenous 489 56.5% 209 51.9% 80 48.4%

Hepatomegaly 330 24.1% 108 26.8% 151 30.1%

Portal vein 96 7% 32 7.9% 23 13.9%

wall thickening

Posterior 276 20.2% 86 21.3% 32 19.4%

Surface
Convex

Border 56 3.7% 29 7.2% 14 8.5%

Irregular

Bumpy 5 0.4% 2 0.5% 1 0.6%

Regular 1032 75.5% 296 73.4% 124 75.2%

Obtuse Liver 18 1.3% 9 2.2% 7 4.2%

Angle

Gallbladder 4 0.29% 3 0.74% 3 1.8%

Small

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 12 0.87% 9 2.23% 4 2.42%

thickening wall

Not observed 2 0,14%

Normal 331 24.21% 96 23.82% 43 26.06%

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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 (Fig.2), 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) (Fig.3). 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 (Fig.1). 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% (Fig.2).
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).
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Fig.1= Active chronic hepatitis Fig.2= Gallbladder wall is usually Fig.3= In acute alcoholic hepatitis,
usually changed liver structure more edematous thickening in acute liver is usually big and
than persistent chronic hepatitis hepatitis and cirrhosis . hyperechogenic (bright liver) with
with coarsening liver parenchyma, attenuation as in fatty infiltrating
and hypoechogenic portal triad but liver .
no attenuation like fatty infiltrating
liver.

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.
This report had been presented at the Asean Association of Radiology (AAR) 9 th in Singapore, 1/1997

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

References:

1. DAFFIRI,R. et al : Apport de l’eùchographie dans la tuberculose des visceøres pleines

de l’abdomen. J.Radio., No 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.
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4. HAGEN-ANSERT, SL: The Liver , pp.99-158, Textbook of Diagnostic

Ultrasonography (Volume 1), 4th ed. Mosby-Year Book, 1995.
5. HUNG THIEN NGUYEN et al : Ultrasound in B and C Hepatitis , MEDIC 1994.
6. HUNG THIEN NGUYEN et al : Changements of Liver Structure Ultrasound in B
and C Hepatitis, MEDIC 1996.