AJR 2002; 178:78
© American Roentgen Ray Society
The "Starry Sky" Liver with Right-Sided Heart Failure
Hani H. Abu-Judeh1
1
Department of Radiology, University Hospital, C Level, University of Medicine
and Dentistry of New Jersey, New Jersey Medical School, 150 Bergen St.,
Newark, NJ 07103.
Received March 30, 2001;
accepted after revision May 22, 2001.
Address correspondence to H. H. Abu-Judeh.
Introduction
Two distinct sonographic patterns in diffuse liver disease have been
described in the literature
[1]. The most common pattern is
the bright liver, which has increased parenchymal echogenicity and sound
attenuation. The bright liver pattern has been seen with fatty infiltration,
chronic hepatitis, acute alcoholic hepatitis, chronic passive congestion, and
cirrhosis [1,
2]. The second pattern is the
centrilobular or starry sky liver, characterized by clearly identified portal
venules and diminished parenchymal echogenicity that accentuates the portal
venule walls. This pattern has been identified in patients with acute
hepatitis [3], leukemia
[3], toxic shock syndrome
[4], Burkitt's lymphoma
[5], and fasting liver
[6]. We recently encountered a
case of right-sided heart failure with tricuspid regurgitation that presented
with a "starry sky" appearance on abdominal sonography. To our
knowledge, this is the first case report describing this hepatic presentation
with right-sided heart failure.
Case Report
A 34-year-old male veteran with tricuspid regurgitation presented with
intermittent abdominal pain and increased abdominal girth. His WBC and liver
function tests were normal. Abdominal sonography showed ascites and diffuse
starry sky appearance of the liver (Fig.
1A). A contrast-enhanced abdominal CT scan showed reflux of
contrast into a dilated inferior vena cava and hepatic veins
(Fig. 1B).
Discussion
The typical liver sonographic findings in right-sided heart failure include
hepatomegaly and dilated inferior vena cava
[7]. Doppler waveforms in
portal vein recordings may have variations that indicate flow characteristics
similar to those of hepatic veins due to transmission of retrograde pressure
waves through the hepatic capillary bed
[8]. Acute hepatitis is the
most common cause of starry sky appearance. This sonographic appearance is due
to the intralobular edematous swelling of the hepatocytes with a resultant
decrease in the hepatic echogenicity. The altered acoustic properties between
the portal venous radicals and hepatic lobules cause sonographic accentuation
of the venule walls [5]. The
pathologic changes in acute hepatitis and other etiologies causing this
pattern consist of necrosis, edema, infiltrate, or inflammation. Less common
causes of starry sky appearance include toxic shock syndrome, leukemia,
fasting liver, and Burkitt's lymphoma. As in acute hepatitis, these hepatic
findings are probably caused by edema of the liver and portal venules.
Right-sided heart failure should be considered in the differential diagnosis
of a starry sky liver.
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Introduction
Case Report
