核醫科 門朝陽醫師

A 54-year-old male with alcoholic liver

cirrhosis, who underwent Ga-67
inflammation scan, was found to have
marked two separated hepatic lobes.
Furthermore, HIDA scan and Liver scan
with SPECT shows there are small region
of adhesion between two hepatic lobes.
Past history& surgery Hx:
liver cirrhosis child A-B ascitis and alcoholi
sm.
 UGI bleeding history, hepatic coma
 Gouty arthritis, right
 EV, congestive gastropathy.s/p EVL
 Anxiety disorder
 Right ureteral stone
 Right femur intertrochanteric fracture S/P ORIF
and DHS.
 Abdominal sono(92/10/27):
 Liver cirrhosis with splenomegaly
 Mild ascitis. GB wall thickening
 Nuclear medicine studies:
 HIDA scan: r/o cholecystitis
 Ga-67 inflammation scan: infection?
 Liver scan with SPECT: study
 Enterogastric refulx study and GET.
Radiological study:
 Abdominal CT
2001-5-22; 2001-10-31;2004-3-1
comparison and shows:
CT report:
 We trace his previous CT scans found
this case has gradually caudate lobe
atrophy. This interesting finding
--marked two separated hepatic lobes,
may help us to diagnosis unusual type
of caudate lobe atrophy with alcoholic
liver cirrhosis.

 Change in size, shape and radiocolloid upta
ke of the alcoholic liver during alcohol withd
rawal, as demonstrated by single photon em
ission computed tomography
The volume of the total liver and separate right and left lobes was studied bef
ore and after 1 week of alcohol withdrawal in 16 consecutive alcoholics by
means of single photon emission computed tomography after intravenous
injection of 99Tcm-human albumin colloid; the relative tissue distribution o
f radioactivity was also followed. The left liver lobe increased in volume m
ore than the right lobe during drinking and decreased more rapidly after al
cohol withdrawal. Median volume reductions during 1 week of alcohol wit
hdrawal w ere: total liver 12%, left lobe 26%, and right lobe 8%, indicating
that half of the reduction to values of a control group was achieved during
this first week. The volume of the right but not of the left lobe was significa
ntly correlated to body size in alcoholics and in controls. The left lobe had
a lower capacity to concentrate the radiocolloid than the right lobe in alco
holics and in controls. The liver/spleen, liver/bone marrow and liver/backg
round radioactivity concentration ratios in the alcoholics increased during
alcohol withdrawal. We conclude that heavy drinking causes both an incre
ased total liver volume and a change in liver shape, with a relatively more
enlarged left than right lobe, as well as a decreased capacity to concentra
te radiocolloid. These changes are rapidly reversible during abstinence fr
om alcohol.
J Hepatol. 1994 Sep;21(3):417-23. Sweden.
Couinaud Segments

Fig 1-1Anterior and posterior view of liver showing 3-dimensional rec

onstructions of helical CT scan data in shaded surface projections wh

ich have been segmented according to the Couinaud classification (d

otted line represents the course of the portal vein which is sometimes
used to to divide segment IV into segments IVa and IVb).

Fig 1-2 Shaded-Surface 3D reconstructions of the liver segments vie

wed in the transverse plane at the level of the rostral part of the liver
and inferiorly from the caudal surface.
Classification and distribution of cirrhosis
 Commen causes:
Alcoholism(western); CAH(HBV)(far east); aut
oimmune(euro caucasians); primary biliary cir
rhosis(>90% F) schistosomiasis(equatorial:fib
rosis but
cirrhosis found in S. japanicum)

Rare but potential:

Wilson; drug induced; biliary atresia hemachr
omastosis; constrictive pericarditis

Rare: cystic fibrosis. Scherosing cholangitis

glycogen storage disease. A1 antitrypsin def.
Pathogenesis:
 The metabolism of ethanol(alcohol) to a
cetaldehyde and acetate dependent to
: alchol dehydrogenase and
acetaldehyde dehydrogenase and need
NADH from NAD(NADPH to NADP)
 In alcoholism the MEOS is induced
 Unwanted by products: hyperuricemia,
hyperglycemia, ketosis, fatty liver.(redox
state of cell in lipid and carbohydrate m
etabolism, steatosis)
Child’s classification of severity of cirrhosis
 Feture points scored for increasing abnormalities
 1 2 3
 Encephalopathy None 1 and 3 3 and 4
 Ascitis None mild mod/sev

 Plasma bilirubin <25 25-40 >40

(mol/l)
Plasma albumin >35 28-35 <28
(g/l)
Prothrombin time 1-4 4-6 >6
(secs prolonged)
Total score: 5-6= grade A; 7-9=grade B;10-15=grade C
Alcoholic liver cirrhosis?
 Is it typical case?(For gap formation)
 Or uncommon case of left hepatic lobe
cirrhosis in segment I( Caudate lobe atr
ophy)?
Or complex to tell due to HBV infection
with ascitis and pleural effusion?
 Caudate lobe atrophy?by CT
 What else could we afford to the clinicians
about liver cirrhosis case?
 What kind of study or variant do we need
to improve in liver cirrhosis case
with EV or case like this?
What do you think?