Congestive Hepatopathy: Pathophysiology, Workup, and Imaging Findings with Pathologic Correlation

Area of Science:

• Radiology
• Hepatology
• Medical Imaging

Background:

• Liver congestion presents diagnostic challenges due to altered hemodynamics.
• Congestion causes diffuse parenchymal changes and nodule development, mimicking malignancy.
• Distinguishing benign focal nodular hyperplasia (FNH)-like nodules from hepatocellular carcinoma (HCC) is difficult.

Purpose of the Study:

• To discuss the pathophysiology of liver congestion and nodule formation.
• To review imaging findings and mimics of liver congestion and hypervascular lesions.
• To propose a diagnostic algorithm for hypervascular liver lesions in congested livers.

Main Methods:

• Review of complex liver macro- and microhemodynamics in congestion.
• Analysis of imaging features differentiating benign from malignant nodules.
• Evaluation of the limitations of the Liver Imaging Reporting and Data System (LI-RADS) in congested livers.

Main Results:

• FNH-like nodules and HCC share overlapping imaging features in congested livers.
• Standard LI-RADS criteria lack specificity in this setting.
• Morphologic changes and increased liver stiffness complicate cirrhosis diagnosis.

Conclusions:

• Liver congestion requires a tailored approach to imaging diagnosis.
• Radiologists must be aware of diagnostic pitfalls in congested livers.
• A new conceptualization and diagnostic algorithm are needed for hypervascular lesions in congested livers.