INDIVIDUAL ASSIGNMENT

GASTROINTESTINAL
2 year / 3 Semester / 2021 / FMUI 2020
st st

Mohamad Arbian Karim

2006489400 – Group A

PBL Trigger 4

How is The Diagnosis of Hepatitis using Radiology Examination and Biopsy

Introduction
Hepatitis is characterized as liver inflammation caused by a range of factors such as high
alcohol use, autoimmune disease, medications, or pollutants. Hepatitis is most commonly
caused by a viral infection, which is referred to as viral hepatitis.1

Hepatitis can range in severity from mild and self-limiting to severe sickness needing liver
transplantation, depending on the cause. Hepatitis is characterized as acute or chronic
depending on how long the inflammation/injury to the liver lasts. Acute hepatitis is defined as
liver inflammation that lasts less than 6 months, whereas chronic hepatitis is defined as liver
inflammation that lasts longer than 6 months. Acute hepatitis is normally self-resolving, but
depending on the cause, it might lead to fulminant liver failure. Chronic hepatitis, on the
other hand, can result in liver damage such as fibrosis, cirrhosis, hepatocellular carcinoma,
and portal hypertension, all of which can result in severe morbidity and death.2,3

Since the etiology of increased liver enzymes are many. In this LTM, I will be discussing
about the diagnosis of Hepatitis using Radiology, Biopsy, and other diagnostic tools that can
be used to help diagnose the correct cause of hepatitis disease on the patient.

Topics Discussion
A. Radiology
Other than laboratory exams that are essensial for diagnosis of hepatitis, imaging
examinations such as ultrasonography, CT scans, and MRIs are very important in the
diagnosis of hepatitis.1

The use of Doppler ultrasonography and color Doppler in the investigation of vascular
structures of the abdomen, particularly the liver, has become commonplace.
According to reports published in the literature to date, all patients with hepatic
cirrhosis and chronic hepatitis should be investigated utilizing Doppler methods in the
early stages of their illness and throughout follow-up. We can now acquire a better
and more thorough vascular analysis of the liver with new ultrasound software and the
current generation of contrast agents, which was previously only possible with triple-
phase CT. Hepatic cirrhosis and chronic hepatitis, as well as associated vascular
consequences, can be tracked more precisely as a result. Flow changes in the hepatic
artery and veins, portal hypertension, portal vein thrombosis, portosystemic shunts,
and vascularization associated with liver malignancies are all vascular problems.4

1. Acute Hepatitis
In acute hepatitis, you can see these findings:5
1. Hepatomegaly
2. Diffusely Hypoechoic Parenchyma
3. Starry sky appearance
4. Thick-walled gallbladder, most common in acute hepatitis A
5. Acute alcoholic hepatitis
a. High-velocity hepatic artery
b. Elevated hepatic artery peak systolic velocity (PSV) > 100 cm/s
6. Acute or fulminant hepatotoxity
a. May see markedly elevated resistive indices of hepatic artery

Fig 1. Acute Hepatits in Doppler USG.5

2. Chronic Hepatitis

In chronic hepatitis, you can see these findings:5

1. Nodular liber surface contour
2. Coarse echogenic parenchyma
3. Hepatomegaly (early stage)/normal size/shrunken
4. Enlarged caudate lobe and lateral segment of left lobe
5. Atrophy of right lobe and medial segment of left lobe
 6. Signs of Portal Hypertension
a. Splenomegaly
b. Portosystemic shunts, varices
c. Ascites
7. Signs of hypoalbuminemia
a. Ascites
b. Edomatous gallbladder wall and bowel wall

Fig 2. Chronic Liver Disease with Cirrhosis in doppler USG.5

B. Biopsy
Liver biopsy is the outcome of a clinical choice that weighs the risk for procedure-
related morbidity and death (varying from 0.009–0.11%) against the potential for
diagnostic and/or prognostic information.6

For the clinical issue of alcoholic liver disease (ALD), liver biopsies are occasionally
performed, however individuals with ALD are generally handled without biopsy.
Hereditary hemochromatosis is a clinically recognized condition that may warrant a
biopsy in people above the age of 40 to check for fibrosis, although it is no longer
necessary for diagnosis or iron quantification. Although it has been suggested that
biopsy is not required for the diagnosis of primary biliary cirrhosis or primary
sclerosing cholangitis, not all clinicians agree; disease processes suggestive of chronic
cholestatic illness may also be seen during biopsy assessment. In cases of acute
hepatitis, liver biopsy is rarely performed since clinical tests can offer diagnostic
information. In the non-transplant setting, the most common procedures seen by
surgical pathologists are biopsy for "chronic" hepatitis or increase of liver tests of
unknown or undetermined origin.6
 Fig 3. Spectrum of ALD, risk factors, and comorbidity. Fatty liver affects more than
95% of heavy drinkers, however only around 35% of this group develops more severe
forms of ALD, such as fibrosis, alcoholic hepatitis, cirrhosis, and HCC. Many risk factors
for severe types of ALD have been postulated. Alcohol use and concomitant variables
work together to hasten ALD development.78

Summary

The use of radiological imaging is important to see the pathology of hepatitis and diagnose
the etiology of hepatitis. Biopsy can also be used even though it is not common, biopsy can
see the progress of the liver tissue which can be helpful in alcoholic liver disease.

References

. Mehta P, Reddivari AKR. Hepatitis. [Updated 2021 Jan 16]. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK554549/.
2. Dakhil N, Junaidi O, Befeler AS. Chronic viral hepatitis. Mo Med. 2009 Sep-
Oct;106(5):361-5.
3. Ryder SD. ABC of diseases of liver, pancreas, and biliary system: Acute hepatitis.
BMJ [Internet]. 2001 Jan 20;322(7279):151–3. Available from:
https://www.bmj.com/lookup/doi/10.1136/bmj.322.7279.151
4. Martínez-Noguera A, Montserrat E, Torrubia S, Villalba J. Doppler in hepatic cirrhosis
 and chronic hepatitis. Semin Ultrasound, CT MRI [Internet]. 2002 Feb;23(1):19–36.
Available from: https://linkinghub.elsevier.com/retrieve/pii/S0887217102900272
5. Diagnostic Ultrasound; Carol M. Rumack 5th ed.
6. Brunt EM. Liver biopsy diagnosis of hepatitis: clues to clinically-meaningful
reporting. Mo Med. 2010;107(2):113–8.
7. Gao B, Bataller R. Alcoholic Liver Disease: Pathogenesis and New Therapeutic
Targets. Gastroenterology [Internet]. 2011 Nov;141(5):1572–85. Available from:
https://linkinghub.elsevier.com/retrieve/pii/S0016508511012285
8. Palleria C, Di Paolo A, Giofrè C, Caglioti C, Leuzzi G, Siniscalchi A, et al.
Pharmacokinetic drug-drug interaction and their implication in clinical management. J Res
Med Sci. 2013;18(7):600–9.